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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701618
Report Date: 07/14/2026
Date Signed: 07/14/2026 02:18:57 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
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211110157
FACILITY NAME:SACRAMENTO SENIOR LIVING IIIFACILITY NUMBER:
342701618
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
07/14/2026
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Facility Staff: Atelaite PetiTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
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On 07/14/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Ateliate 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.

Allegation: The facility allowed excluded individuals to work in the facility.
It was alleged that the facility allowed excluded individuals to work in the facility. This investigation consisted of interviews with facility staff, residents in care and records review. On 2/19/2026 LPA Tamayo conducted a visit to the facility and spoke with one (1) facility staff who stated they have not seen excluded individuals E1 and E2 present inside of the facility. Interview with six (6) residents in care indicated that they have never seen the excluded individuals inside of the facility. LPA Hughes conducted a follow-up visit to the facility on 07/14/2026 and did not observe the excluded individuals working inside of the facility.

Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260211110157
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: 07/14/2026
NARRATIVE
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LPA checked LIC 500 Personnel Report, and Guardian Rosters and did not observe excluded individuals (E1) and (E2) on the reports. There is not enough information or evidence present to corroborate the allegation, therefore the allegation is unsubstantiated.

Allegation: Staff are forging resident documents.
It was alleged that staff are forging resident documents. This investigation consisted of records review. On 06/26/2026 LPA Hughes conducted a visit to the facility and collected resident LIC 602 Physician’s Reports for 5 residents in care. LPA Hughes reviewed the records and verified that 4 out of 5 LIC 602 Physician’s Reports contained physician signatures. On 07/10/2026, LPA contacted the physician’s offices and confirmed that the signatures on the LIC 602 forms were authentic and consistent with the records maintained by the physicians. There is not enough evidence to corroborate that the facility forged or falsified documents. Therefore, this 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: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211110157

FACILITY NAME:SACRAMENTO SENIOR LIVING IIIFACILITY NUMBER:
342701618
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
07/14/2026
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Facility Staff: Atelaite PetiTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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On 07/14/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Ateliate and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 6.

Allegation: The Administrator is not present at the facility for a sufficient amount of time.
It was alleged that the administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with facility staff, residents, and records review. On 2/19/2026 LPA Tamayo conducted a visit to the facility and spoke with facility staff (S2) who stated that the facility administrator is present in the facility a few times per week. Interview with 4 out of 5 residents indicated that while they were aware of the administrator they reported the administrator was present only occasionally and was not frequently observed at the facility.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211110157
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: 07/14/2026
NARRATIVE
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On 06/26/2026, LPA Hughes conducted a follow-up visit and requested updated LIC 500 Personnel Reports to verify the administrator’s presence. Review of LIC 500 Personnel Reports dated 12/31/2025 through 04/08/2026 reflected a change in facility administrators effective 04/08/2026. During an interview, the facility administrator stated they were unaware they had been designated as the facility administrator until 04/17/2026. However, the records reviewed were not consistent with observations made during the investigation or statements obtained from residents regarding the administrator’s presence at the facility. This was observed not in compliance with Title 22 regulation 87405(a), as the facility did not ensure facility administrator presence in the facility for a sufficient amount of time to effectively manage the facility and carry out duties as required by regulation.

Based on the information gathered through this visit, the administrator is not fulfilling administrator duties.
A civil penalty of $1000 is being issued today for a repeat violation of Section 87405(a) by not ensuring there is an administrator applicable to conduct administrator duties at the facility.


As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
 
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211110157
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2026
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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The licensee to submit 40 hour Administrator plan by 07/15/2026 by 5:00 PM.
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This requirement was not met as evidenced by:
Based on resident interviews, facility observations, and records review. The facility did not ensure facility administrator presence in the facility for a sufficient amount of time to effectively manage the facility and carry out duties as required by regulation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5