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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701618
Report Date: 11/20/2025
Date Signed: 11/20/2025 01:02:08 PM

Document Has Been Signed on 11/20/2025 01:02 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: 5DATE:
11/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Josaia SigavataTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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 On 11/20/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a case management -deficiency visit for deficiencies observed on 10/20/25 and 11/7/2025. LPA met with care staff Josaia Sigavata (S1) and explained the purpose of the visit. S1 called Licensee, Salote Lewis, to inform the LPA was at the facility. Licensee told S1 to assist LPA with this visit.

Based on interviews with S1, R3, and R4 stated R4 it was reported that R4 had an ER visit due to sustaining a rib fracture when they were with their family member in which S1 called the ambulance when R4 was complaining of pain on the night of 11/4/25. Discharge paperwork for R4 dated 11/5/25 state R4 obtained a rib fracture (when out with their family on 11/4/25) an incident report was not sent to Licensing. S1 stated Licensee was informed resident was transported via ambulance. At 3:00 PM 11/7/25, S1 stated Licensee was made aware S1 called 911 for R4 due to their rib pain. At around 2:10 PM, LPA spoke with Licensee over the phone on 11/7/25 and they stated there was no recent incidents to report. As of, 11/19/2025 Facility did not meet timely reporting requirements.

Additionally, Record review does not show there was an updated appraisal/care plan for facility staff created for R4 after they were discharged with a fractured rib, which constitutes a change of condition.

Moreover, LPA observed there was a Tylenol bottle that was over half way full next to R4s bed. Tylenol is listed as a PRN for R4, and should locked and inaccessible to resident in a centrally stored location, this deficiency was cited on a separate LIC 9099 dated 11/19/25. On 10/30 and 11/7/25 LPA Tamayo observed the kitchen refrigerator stored a lock box insulin needles for one resident was closed but it opened freely because the it was not locked with a key, S1 and R2 stated they did not know where the key is. Although R1 is able to self administer medications with some assistance, LPA Tamayo observed insulin needles are stored in the mini-refrigerator of R1’s bedroom without any locking mechanism.
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: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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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: 11/20/2025
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At around 1:00PM on 11/7/2025, a maintenance person arrived to repair a hole on the side of the homes exterior leading into the garage as well as the hallway toilet. The maintenance worker told S1 they will remove the toilet and make the repairs by end of day. Resident 1 R1 stated they went to use the bathroom and almost fell into the hole where the toilet was previously placed, "no one told me …. there was no toilet … I could have seriously hurt myself ... I'm blind". S1 stated they did not tell R1 the toilet was removed, because R1 was on the phone. LPA spoke with staff regarding providing accommodations including informing residents with visual impairments if furniture items are moved, ensuring there are no obstructions, or hazards as stated on the needs and services plan. The facility did not ensure accommodation for all residents are being done. LIC 602 for R1 states the resident needs direction with moving around the facility, “ensure environment is clutter free and easy to maneuver … free of tripping hazards … [staff will] provide orientation and mobility training as needed”, however, LPA has not observed staff assist R1 with direction around the facility on 7/28/25, 9/10/25, 10/30/25, 11/7/25, or 11/19/25.

During LPA’s visit 11/7/25, LPA observed the right side basin of the kitchen sink was filled with water and had a sealed packet of meat floating inside the sink. Witness 1 (W1) stated they have seen meat thawing on the kitchen sink on more than one occasion. Staff stated they would get a separate basin to thaw meats.
LPA conducted record review of staff records for S1, S2, S4, and S5 and there was no staff file for S5, incomplete documents for S4, including LIC 501 , and there were incomplete training verifications available for review for S1, S2, S4, and S5. On 11/19/25, LPA observed S1 was using a separate designated basin to thaw a steak that was going to be prepared for dinner.

Additionally, It was reported that Staff 1 (S1) had their family over on the evening of 11/6/2025 for dinner time. Staff is not able to host personal gatherings especially with individuals who do not have criminal background and TB clearance prior to entering the care home.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation. An exit interview was conducted with the Licensee, and a copy of these LIC 809, 809-D reports 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: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/20/2025 01:02 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 11/19/2025 at 06:22 PM
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: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2025
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency (1) A written report ... submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...
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By POC due date Licensee will submit incident report for R4 to licensing and responsible party along with a statement agreeing to review 87211(a)(1) and report all special/unusual incidents to licensing and responsible parties in a timely manner
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this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.
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Type B
12/04/2025
Section Cited
CCR87463(a)

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87463 Reappraisals (a) ... as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary ... to note significant changes in conditon...referred to as the reappraisal.
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By POC due date, licensee agrees to review 87463(a) and complete a reappraisal for any resident that has not had one in the last 12 months or if there has been a change in condition since the last reappraisal.
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This requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2025 01:02 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 11/19/2025 at 06:22 PM
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: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipmentthis requirement was not met as evidence by:
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By POC due date, Licensee will submit a statement of review and understanding of 87468.1 along with a plan ensure only authorized individuals are allowed in the care home and a plan to accord accommodations for residents whom need assistance with navigating the facility.
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Care staff did not accord residents, including residents with blindness, timely notification that the toilet was removed for maintenance on 11/7/25 resulting in an incident in which R1 going to use the bathroom as usual without knowing the toilet had been removed. Additionally, the two resident interviews in which it was learned that care staff using work hours for personal social gathering on 11/6/25, this shows failure to perform required duties and introduced uncleared individuals to the environment. This poses an immediate health risk to residents in care.
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Type B
12/04/2025
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h) ... to medications which are centrally stored: (2)... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication ...
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By POC due date, licensee will ensure all medications are stored properly and with a locking mechanisms locked/inaccessible to residents who are not able to self administer medications along with a plan to train staff on 87465.
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this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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