342701618-6-26-2026-27-AS-LRIS-DVJV6V-20260630161010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701618
Report Date: 06/26/2026
Date Signed: 06/26/2026 04:15:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2026 and conducted by Evaluator Shakaricka Hughes

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260403101811

FACILITY NAME:	SACRAMENTO SENIOR LIVING III		FACILITY NUMBER:	342701618
ADMINISTRATOR:	FELIPE NAIKASO		FACILITY TYPE:	740
ADDRESS:	8901 SONOMA VALLEY WAY		TELEPHONE:	(530) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY:	6	CENSUS: 6	DATE:	06/26/2026
		UNANNOUNCED	TIME BEGAN:	02:48 PM
MET WITH:	Facility Staff: Atelaite Peti		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not report communicable disease.
Facility staff did not properly monitor residents glucose resulting in hospitalization.

INVESTIGATION FINDINGS:

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On 06/26/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Atelaite and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6. The facility administrator was not present during today's visit.

Allegation: Facility staff did not report communicable disease
It was alleged that facility staff did not report communicable disease. This investigation consisted of interviews with residents, facility staff, and records review. On 04/17/2026 LPA Hughes conducted a visit to the facility and interviewed 4 out of 4 residents in care. Interview with 2 out 4 residents stated that they were aware of a resident in care recently being diagnosed with a communicable disease. Interview with resident (R2) stated that they were diagnosed with a communicable disease, received treatment, and was told by the physician the disease was not contagious.

Continuation 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260403101811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO SENIOR LIVING III	FACILITY NUMBER: 342701618
	VISIT DATE: 06/26/2026

NARRATIVE

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R2 further stated that the facility took additional precautionary measures and sent the resident for further testing. Interview with the facility staff (S1) stated that the resident was sent out to the hospital and the facility did receive confirmation that the resident communicable disease was not contagious. LPA reviewed resident records, LIC 602 Physician’s report and notes which indicated the resident does not have any signs of active communicable disease and is non-contagious. LPA reviewed the LIC 624 Unusual Incident/ Injury Report sent to CCLD on 04/10/2026 which detailed the resident concerns and facility action. Additionally, LPA reviewed LIC 602 Physician’s Reports for 5 out of 5 residents which indicated negative results for communicable diseases for residents in care. There is not enough information or evidence available to corroborate this allegation. Therefore, the allegation is unsubstantiated.

Allegation: Facility staff did not properly monitor residents glucose resulting in hospitalization

It was alleged that facility staff did not report communicable disease. This investigation consisted of interviews with residents and facility staff. On 04/17/2026 LPA Hughes conducted a visit to the facility and interviewed Resident (R1), who stated they were last hospitalized in September 2025 due to blood glucose levels and had not been recently hospitalized as a result of facility staff failing to monitor their blood glucose. LPA also interviewed Resident (R2), who stated they do not require assistance from facility staff with blood glucose monitoring, and have not been hospitalized due to blood glucose concerns. Additionally, LPA interviewed facility staff (S2) who stated they were not aware of any recent hospitalization related to inadequate glucose monitoring and reported that (R1) received appropriate care with blood glucose monitoring and care. Based on the information obtained during the investigation, there was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

LIC9099 (FAS) - (06/04)

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