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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701618
Report Date: 11/19/2025
Date Signed: 11/19/2025 05:00:15 PM

Substantiated


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
11/04/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20251104081616
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: 5DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
03:44 PM
MET WITH:Josaia SigavataTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not ensure the facility is free of rodents and insects.
Staff did not ensure safe assistance with glucose testing is available to diabetic residents.
Staff did not ensure modified diets as prescribed by a resident's physician are provided to residents.
Staff did not ensure timely administration of medications.
Staff does not have sufficient training on preparing diabetic-appropiate meals for residents with diabetes.
Staff did not ensure there are an adequate number of staff to meet residents needs.
Staff did not ensure there is awake staff 24/7.
Staff did not ensure there is a working alert device feature on exterior doors at all times.
Staff does not provide activities for residents.
Administrator does not spend sufficient number of hours at the facility.
Administrator does not assist to meet health care needs for resident for annual doctors visits.
INVESTIGATION FINDINGS:
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At 3:44 PM, on 11/19/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a complaint visit. The purpose of this visit is to complete and deliver complaint findings for the allegations aboveLPA met with care staff Josaia Sigavata and explained the purpose of the visit. A brief interview conducted with care staff, Josaia Sigavata.

The current census is five residents with one staff.

It was alleged that staff did not ensure the facility is free of rodents and insects. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. During multiple unannounced visits conducted on 10/30/25, 11/7/25 and 11/19/25, LPA observed there were flies in the kitchen area. On 11/7/25, at around 2:00 PM, LPA observed the kitchen trash bins, hallway bathroom trash bins, trash bins in two residents’ bedrooms were full and in need of disposal.
CONTINUED ON 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 11
Control Number 27-AS-20251104081616
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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2025
Section Cited
CCR
87628(b)(4)
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87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7).
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By POC due date, the facility will submit a plan to ensure there are diabetic appropriate meals for residents in care who have a diagnosis of diabetes meals as well as ensure trained staff to provide timely and safe assistance with medication administration.
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This requirement is not met as evidenced by interviews that reveal diabetic resident, R1, has missed meals and is not being offered meals that are appropriate for their diabetic and dietary needs. On 11/7/25, R1 did not have breakfast nor medication until 2:28PM. On 8/27/25, R1 was hospitalized after a keto acidosis episode. The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for special diet needed for residents with diabetes.
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Type B
12/03/2025
Section Cited
CCR
87303(f)
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87303 Maintenance and Operation (f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents...
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By POC due date, licensee will submit a plan to ensure the facility is free of pests, rodents, and insects including a scheduling an exterminator to start to treat for pests, rodents, and insects before 12/19/25. Licensee will also provide staff with a cleaning schedule and training including the requirement to
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This was not met as evidence by: Based on interviews with staff and residents confirming there is a mouse infestation. This posed a potential health and safety risk to residents in care.
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 take out the trash in all rooms twice a day or more if needed and doors are closed in order to prevent rodents or insects from entering the home.
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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
CCR
87628(a)
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87628 Diabetes (a) ... resident who has diabetes ... able to perform his/her own glucose testing .... able to administer his/her own medication .... or has it administered by an appropriately skilled professional. This was not met as evidence by: Based on
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by POC due date, the facility agrees to ensure residents who have diabetes are able to administer his/her own medication safely or has it administered by an appropriately skilled in a timely manner.
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 interviews and observation, in which it was observed that Staff 1 (S1) did not ensure to safe administration of insulin was done by not using gloves nor use sterilizing pad when assisting resident 1 (R1) with their medications and that timely administration of medications is taking place. This posed an immediate or potential health and safety risk to residents.
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Type B
12/03/2025
Section Cited
CCR
87411(d)
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87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning.
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By POC due date, licensee will ensure there is an updated training on ensure modified diets as prescribed by a resident's physician are provided to residents and an updated meal is created along with staff and residents
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This was not met as evidence by: Based on interviews and observations, it was learned staff is still not adequately trained on providing modified diets as prescribed by a resident's physician, dietary restrictions, and resident preferences are provided to residents.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met as evidenced by interview and observations
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by POC due date, licensee will submit plan to ensure there is at least two care staff to ensure needs of five residents in care including ensuring there is enough staffing to ensure transportation to and from medical appointments for residents are accounted.
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in which it was learned one care staff is not enough to meet the needs of five residents in care. Additionally, there should be wake staff at night time due to the facility having an exit seeking resident with a diagnosis of dementia; this poses a potential health and safety risk to residents in care.
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Type B
12/03/2025
Section Cited
CCR
7219(a)(1)
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7219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:(1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to...
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by POC due date, facility will create an activity calendar and staff tracings to plan, coordinate, and follow through of the provision of enrichment activities for as outlined in the plan of operation, admission agreements, appraisal for residents.
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This requirement was not met as evidenced by interview observations and interviews in which it was leaned no activities are being offered to residents in care. This poses a potential health and safety risk to residents in care.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2025
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties(a) ... qualified ... administrator shall have sufficient freedom from other responsibilities... on the premises a sufficient number of hours... attention to the management and administration ... a designated substitute ... qualifications adequate to be responsible and accountable for management and administration
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By POC due date, Licensee will submit a request to update administrator, updated LIC 308, and updated LIC 500 by POC due date. Licensee ages to designate an administrator and administrator institute who shall have qualifications adequate to be responsible
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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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e 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.
Type B
12/03/2025
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a ) A plan for incidental medical and dental care ... routine medical and dental care and provide for assistance in obtaining such care.. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents
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By POC due date,licnesee will submit plan to ensure all residents have assistance with scheduling and attending routine medical visits as required for each resident.
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This requirement was not met as evidence by record review and interviews in which it was learned that 4 out of 5 residents not having dental care verification in over a year as well as routine medical doctors visit. Additionally, resident 1 (R1) has missed medical appointments due to not having assistance with transportation arranged. this poses a potential health an safety risk for residents in care.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
NARRATIVE
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LPA talked to staff regarding the importance of taking out the trash more than once a day, as needed to keep the facility clean, order free, and free of rodents and insects.

On 10/30/25, LPA observed there was a cat in the facility, two residents reported the cat was brought in due to the "mouse problem". On 10/30/25, LPA observed there was a hole on the exterior wall on the right side of the home of the home which leads into to the garage. Licensee stated they would repair the hole. On 11/7/25, LPA observed a maintenance worker was working on covering up the hole on the side of the house. Two residents stated there are cockroaches and flies in the home. On 11/7/25, Licensee stated they would look into placing screen doors and a secure cat door to prevent rodents and insects from entering the home. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation staff did not ensure the facility is free of rodents and insects.

It was alleged staff did not ensure safe assistance with glucose testing is available to diabetic residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. During an unannounced visit conducted on 11/7/25 at around 2:18PM, R1 stated they have not had any breakfast and have been waiting for their medication and breakfast since the morning. S1 reminded staff they needed to have their medication before having their meal. LPA observed S1 obtain an insulin pen injector from R1’s mini fridge, which was accessible without any locking mechanism. LPA observed S1 did not have any alcohol prep pads nor were they wearing any gloves when handling resident medications. On 9/10/25, LPA discussed the need to providing staff training for staff caring for with diabetes and an updated plan to address the care needs for residents with social diets and blood sugar checks, of which a plan of correction was submitted 10/8/25. Additionally, during multiple visits including 10/30/25, 11/7/25, and 11/19/25, LPA observed medications assistance were administered at different times each day.Witness 2 (W2) stated R1 attended a medntal health appointment at 10:00AM without eating anything prior, which resulted in the CGM constantly beeping due to low blood sugar readings. R1 stated they requested staff to knock their door and wake them up in the morning to ensure they do not miss medication administration or meals in the mornings to ensure their glucose level is not disregulated. on 8/29/25, R1 was hospitalized due to having keto acidosis. On 11/7/25, R1 did not have any breakfast until 2:28PM. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation.

It was alleged that staff did not ensure modified diets as prescribed by a resident's physician are provided to residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies.
CONTINUED ON 9099-D.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
NARRATIVE
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Record review revealed that the appraisal for R1 dated 5/ states they are on a restricted carb diet, and is vegetarian, the LIC 602 form in which their needs and services care plan states that staff will accommodate alternatives are not available for residents who Vegetarian or have diabetes. The appraisal/needs and services plan for R1, dated 5/8/25 states the staff will provide “diabetic vegetarian meals” and daily insulin checks.

During an unannounced visit conducted on 11/7/25 at around 2:18PM, R1 and witness 1 (W1) stated they had not had any breakfast and needed to eat hours ago. S1 stated R1’s meal was ready and, in the microwave, until they were ready to eat. R1 stated they have been ready to eat since the morning and reminded staff they needed to have their medication before having their meal. S1 stated R1 did not ask for breakfast and they only had coffee. After medication was provided to R1, LPA observed R1’s meal was served at around 2:28PM which consisted of a bowl of scrambled eggs with cheese. S1 stated one resident had pancakes for breakfast and another had eggs that same morning. LPA observed R3 has sausage sandwich for lunch at around 2:00 PM.

On 11/7/25, S1 showed LPA there was a special diet menu posted on the inside of the kitchen cabinet of which the menu did not show what was to be served on Fridays not does the menu provide alternatives for residents with special diets whom does not eat any meats. There are three residents with diabetes and two residents that do not eat meat(s) and/or pork. The posted menu from the plan of correction dated 10/8/25, lists breakfast to be French toast, bacon, orange slices, and milk and the lunch option lists: tuna salad sandwich with vegetable soup.

LPA observed inventory of the kitchen foods does not obtain all foods listed on the posted menus. R1 buys their own food because the facility is not accommodating their dietary needs and preferences. W1 stated “what they provided , given hashbrown and toast for breakfast. Blood sugar levels are all over the place … Caregiver asks Cody what to cook instead of knowing what they can have”. On 11/19/25, At 4:50PM LPA observed S1 begin to prepare dinner. S1 stated dinner would be steak, mashed potato, and watermelon for dinner of which Tofu would be offered as a meat alternative.

Moreover, LPA observed there is a separate menu posted in the hallway bulletin board that is titled, “Weekly Menu For Sacramento Senior Living Residents (Diabetes And Hypertension)”, of which breakfast should have been Greek yogurt, strawberries, and a muffin and lunch is chickpea curry, rice, and salad. LPA did not observe any of these options to be offered or available to residents with diabetes.
CONTINUED ON 9099-D
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
NARRATIVE
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 Witness 2 (W2) stated R1 attended a medntal health appointment at 10:00AM without eating anything prior, which resulted in the CGM constantly beeping due to low blood sugar readings. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation.

It was alleged that staff did not ensure timely administration of medications. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. LPA conducted record review of 5 out of 5 resident records, R1’s LIC 602, reveal R1 they are able to administer medication but needs assistance with ensuring it is the correct dosage and may need help denying medications due to being blind. S1 residents stated there is only one care staff during each shift to care for five residents and medications have not been given at the same time each day because residents are sometimes asleep and do not wake up. Staff will put a plan is in place to ensure medications are administered around the same time frame each day for each resident moving forward. Based on observation, records review and interviews statement conducted during the investigation process Tamayo Lee was able to corroborate the allegation.

It was alleged that staff does not have sufficient training on preparing diabetic-appropriate meals for residents with diabetes. LPA interviews with two residents, one staff, and LPA observations from 10/30/25 and 11/7/25, staff does not have sufficient training on preparing diabetic-appropriate meals to meet the needs of three diabetic residents residing in the home. LPA’s resident record review reveals that the appraisal/needs and services plan for R1, dated 5/8/25 states the staff will provide “diabetic vegetarian meals”. On 9/2/25, Licensee submitted an unusual incident report that reported R1 was sent to Emergency Department on 8/27/25, as R1 was “staff observed resident vomiting. Due to his diabetic condition incident was immediately treated as urgent”. Discharge records reveal R1 had Keto acidosis. The plan of correction dated 9/10/25, agreed to provide staff training for staff caring for with diabetes and an updated plan of care including a monthly menu to be implemented to address the care needs for residents with social diets and blood sugar checks to be implemented by 10/8/25. LPA has only observed eggs, oatmeal, rice, and sandwiches to be served for breakfast and lunch on past visits. LPA has not observed there to be alternatives offered to residents before or during meal times. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation, in which a $250 civil penalty for repeat violation applies.

It was alleged that staff did not ensure there are an adequate number of staff to meet residents needs. CONTINUED ON 9099-D
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
NARRATIVE
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The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. Two residents stated there is only one care staff during the day and they clean, cook, change residents, bathe residents. Three residents stated the licensee is only there a “few hours” per week. Two residents stated that most needs are being met but the quality of care is not there, and it is too much work for one care staff to do. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation.

It was alleged that staff did not ensure there is awake staff 24/7. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party. On 9/11/25, facility submitted a plan of correction in which they agreed to have overnight staff due to elopement of one resident with a diagnosis of dementia. . Licensee stated there is one wake staff, staff 3 (S3), but residents don’t see them because they are in their rooms, S3 is scheduled from 10:00PM- 6:00AM every day. Per LIC 500, S4 is scheduled on weekends between 7AM-7AM, Licensee confirmed was no night staff on 11/6/25, but they were there days prior. License stated there was no back up wake staff for the designated night staff is not working such as on 11/6/25. S1 stated there has not been night staff for a “couple of weeks”. Four residents stated they have not seen any night staff aside from S1 who sleeps in the staff room, usually after 10:00PM. On the night of 11/4/25 , residents alerted S1 that R4 needed to go to the hospital and S1 called 911. S1 stated it was after 10:00PM and they were the only staff present. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation.

It was alleged that staff did not ensure there is a working alert device feature on exterior doors at all times. The investigation included observations, record review, and interviews with facility staff, residents in care and residents’ responsible party. On 10/30/25, the facility was cited for not ensuring there is a working alert device feature on doors at all times via a case management visit. There is a recent plan of correction stating that licensee will put a plan in place to installing a hard-wired alarm system on exit doors. LPA confirmed a hardwired alarm system has been installed as of 11/10/25.
Device to be installed within two weeks of citation issuance. On 10/31/25, W1 stated that the alarm system was off. Based on observation and interviews statement conducted during the investigation process, the allegation is substantiated. A new citation will not be applied due to the facility being cited on 10/30/25 in which the plan of correction has now been completed.
CONTINUED ON 9099-D
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
NARRATIVE
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It was alleged that the staff does not provide activities for residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party. Record review reveal the appraisal/needs and services plan for R1 sta-R3 state that staff will to facilitate participation in social activities and daily access to activities. On 11/7/25, LPA observed the posted activity calendar on the bulletin board is for activates offered in July and August. Three residents stated the majority of the activists listed on the activities calendar were offered not to residents except for an attempt to have a BBQ on the fourth of July and some movie nights. On 9/10/25, 10/30/25, and 11/7/25, LPA has not observed any activities being offered to residents aside from residents watching television in their bedroom and/or in the living room. Based on observation, records review and interviews statement conducted during the investigation process LPA was able to corroborate the allegation.

It was alleged that the Administrator does not spend sufficient number of hours at the facility. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. Sacramento Senior Living III was licensed April 2025, in which Tevita Kaloulasulasu (A1) is the designated Administrator. On 11/7/25, LPA observed the posted LIC 308 lists A1 as the Designated Facility Responsible person. On 11/7/25, two staff and two residents stated A1 has not been working at the facility for over a month. LPA was not aware that Former Administrator Kaloulasulasu had stopped performing administrator duties and responsibilities and is no longer working at this facility. One outside witness also confirmed that they have not met or communicated with an Administrator at the facility and have only interacted with care giving staff.

Licensee, Licensee (Charlotte) Lewis (L1) stated they are filling in as the administrator in the meantime in addition to being an administrator at two other facilities. LPA observed the updated LIC 308 listing care staff, S1, as the Designated Facility Responsible person was not yet updated on the facilities records included the posted LIC 308 dated 8/2025.

During unannounced visits conducted on 10/30/25 and 11/7 did not observe an Administrator or licensee present at the facility. LPA advised staff to review Title 22 requirements to have a qualified administrator to cover for the administrator when the administrator is not available. License shall update the administrator and facility designated responsible person, since A1 is no longer working at the facility.
CONTINUED ON 809-D
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 27-AS-20251104081616
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: 11/19/2025
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Per LIC 308, licensee agreed to notify licensing in writing within ten days of any change in the LIC 308 authorizations, the facility did not notify licensing of this change timely. Based on observation, records review and interviews statement conducted during the investigation process, LPA was able to corroborate the allegation.

It was alleged that the Administrator does not assist to meet health care needs for residents for annual doctors’ visits. The investigation included observations, record review, and interviews with facility staff, residents in care, residents responsible party, and outside agencies. Three residents stated they have not had any dentist appointments in the last year. Two witnesses, W1 and W2 stated one resident has missed medical appointments due to not having transportation as a result of the facility not having enough staffing or administrator oversight. Licensee stated they have not arranged any dental appointments for residents who have not had the required dental visits prior to becoming licensed in April 2025, but will make arrangements for all residents to have the required annual medical appointments this month. Based on observation, records review and interviews statement conducted during the investigation process LPA was able to corroborate the allegation.

As a result, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff, S1, and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 11 of 11