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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701618
Report Date: 09/10/2025
Date Signed: 09/10/2025 12:41:50 PM

Document Has Been Signed on 09/10/2025 12:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIIFACILITY NUMBER:
342701618
ADMINISTRATOR/
DIRECTOR:		KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 6DATE:
09/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:KALOULASULASU, TEVITATIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 9/10/25 at 9:02 AM Licensing Program Analyst (LPA) Cynthia Tamayo conducted an unannounced case management inspection to address previous incident reports and deficiencies in facility operation. LPAs met with administrator, Tevita Kaloulasulasu (S1) and together discussed incident reports from 8/29/25.

LPAs conducted file review and observed LIC 603A physician's report is dated 12/21/2023 and Resident 1 (R1) is need of an updated version. S1 stated R1 has an appointment with physician to get an updated physicians report on 11/11/25.

Based on LPA observations, interviews, and resident file review, LPA has determined, based on resident needs, there must be awake night staff available at the facility to meet resident needs during overnight hours. S1 stated they are asleep overnight. Staff performing overnight duties must be awake during all hours of the overnight shift. The department has determined the facility did not meet resident needs for care and supervision per the current Personnel report (LIC 500) and residents with diagnosis with dementia. This was documented by an incident report dated 8/29/25 where R1 eloped from the facility and the resident's physician report indicated that resident is unable to leave the facility unassisted.

The department received an incident report from 8/27/25 regarding Resident 3 (R3). Staff will obtain updated physicians report and complete a re-appraisal this month. Staff stated R3 and R4 are able to perform their own glucose testing with blood specimens, and is able to administer own medication including medication administered orally or through injection.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/10/2025 12:41 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 09/10/2025 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO SENIOR LIVING III
FACILITY NUMBER: 342701618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
87411(a)

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87411Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs ... shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and
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The administrator/licensee has agreed review regulation 87411(a) and provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision by POC due date.
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 maintenance of buildings, equipment and grounds... licensing ... may require... to provide additional staff... This requirement was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
10/08/2025
Section Cited
CCR87628(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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The administrator/licensee will conduct staff training for persons caring for with diabetes and updated plan of care including a monthly menu will be implemented to address the care needs, specifically for social diets and blood sugar checks for residents with diabetes.
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This requirement is not met as evidenced by:
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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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/10/2025
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S1 stated they are seeking to obtain home health nurse assistance for R3 to have an appropriately skilled professional start to assist R3 with checking their blood sugar due to R3 being blind and need for a re-assessment. Based on LPA observations, interviews, and resident file review, LPA has determined, special diet is not being followed for residents with diabetes.

Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. An Immediate $500 civil penalty was issued during today's inspection.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
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