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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701618
Report Date: 12/23/2025
Date Signed: 12/23/2025 05:55:09 PM

Document Has Been Signed on 12/23/2025 05:55 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:
12/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Josaia SigavataTIME VISIT/
INSPECTION COMPLETED:
04:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management visit on incident reports received. LPA met with Josaia Sigavata (S2) and explained the purpose of the visit. Licensee (S1), Salote (Charlotte) Lewis, was not present during this visit. S2 stated that S1 was present at the facility this morning. LPA called S1 and left a voice message requesting a call back.

The purpose of this visit is to follow up on an incident report and death report received for Resident 4 (R4). The incident received for R4 was dated 12/16/2025 regarding a resident being sent out to the hospital due to R4‘complaining of abdominal pain’. A Death report for R4 is dated 12/16/25 states that R4 died at the hospital on 12/15/25 due to “multiple underlying conditions”. S2 stated they do not know if the death certificate has been requested.

Per records review, R4 was admitted to this facility on 6/3/2025.
During a case management visit in November 2025, it was discovered that R4 had was transported to the emergency room on 11/4/25 due to a sustained rib fracture the day prior while out with their family, the facility did not submit a timely incident report.

On 11/20/25, a deficiency was cited for 87211 Reporting Requirements (a)(1) which consisted of 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 by 12/4/25. Incident report (SIR) dated 11/4/25 for R4 was not submitted to LPA as stated on POC due date 12/4/25; LPA observed SIR dated 11/4/25 was available for review at the facility (SIR binder).

Contunued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2025
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: 12/23/2025
NARRATIVE
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 Licensee will submit an additional SIR regarding the incident, as the one on file does not inform of the diagnosis of fractured ribs and discharge details. LPA observed R4’s reappraisal dated 11/4/25 was not in R4’s physical record/binder maintained at the facility. The re-appraisal was submitted to LPA via email. LPA observed all medical visit verifications including discharge paperwork, after care summaries for R4 were not available for review at the facility during this visit. LPA reviewed POC requirements and record keeping requirements with S2.

As of 12/23/25, CCLD has not received a request to change administration designation to S1; the current assigned administrator is S2, whom is no longer working at the facility and is now disassociated. S1 stated they will submit a request to designate themselves as administrator. A civil penalty for repeat violation applies.

On 12/22/25, LPA spoke with S1 via phone call to follow up on administrator status, S1 stated they are still in the process of hiring a new administrator and they are acting as administrator for this facility. At around 2:30PM on 12/23/25, S1 informed LPA they are not able to come to the facility during this visit due to being in Rocklin for “networking for administrator… Ill be there again this evening”. At around 4:08 LPA Tamayo and S1 set up a phone call for 12/24/25 at 9:30AM.

At 3:40PM during this visit, LPA Tamayo observed a new resident arrived and was moving into the facility during this visit. S2 stated admission packet is set to be completed with the new resident this evening.

LPA is requesting the following facility documents to be submitted by 12/24/25:
November and December LIC 500s, LIC 9020, visitor sign in/out sheet (September - December)
Additionally, the following records for R4 if they have not yet been submitted to LPA Tamayo on 12/23/25: All appraisals, admission agreement, LIC 601, LIC 602, incontinence logs, daily notes, Home health contact information, home health care plan and notes, verification of all incident reports, all doctor visit appointments, after care summary, all discharge paperwork, death certificate.

As a result of this case management , there are two Title 22 Regulation deficiencies cited. Deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the S2.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2025 05:55 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 12/23/2025 at 10:18 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: 12/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2025
Section Cited
CCR
87465(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. This repeat vioaltion constitutes a civil penalty.
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this requirement was not met as evidence by the facility continuing to not ensure medications/insulin is stored properly and with a locking mechanisms and is locked/inaccessible to residents, this poses a potential/immediate health risk to residents in care.
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Type A
12/24/2025
Section Cited
CCR87405(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 ... a designated substitute ... qualifications adequate ...
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By POC due date, Licensee will submit a request to update administrator to community care licensing. Licensee will also submit a statement of understanding of 87405(a) and requirement to designate an administrator and administrator substitute(s) who shall have adequate qualifications.
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this requirement was not met as evidenced by licensee not updating the assigned facility administrator with community care licensing by previous POC due date 12/3/25, this poses a health and safety risk to residents in care.
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This is a repeat violation and a civil penalty applies.
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: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


LIC809 (FAS) - (06/04)
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