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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701618
Report Date: 02/19/2026
Date Signed: 02/19/2026 06:59:51 PM

Document Has Been Signed on 02/19/2026 06:59 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:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Atelaite PetiTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 2/19/2026, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at Sacramento Senior Living III for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Atelaite Peti (S3). Upon arrival, the Administrator (S1) was not present at the facility, S3 contacted S1 to inform them of the purpose of today's visit. An entrance interview was conducted.

Sacramento Senior Living III is a residential care elderly (RCFE) licensed to serve 6 adults age range 60 and over. Approved for 6 non-ambulatory. Waiver/granted for hospice care for (2). LPA observed there to be one staff and and five residents in care, of which none are in hospice.

LPA toured the facility with S3 and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. S1 will ensure the thermostat is operating at all times and the temperature is set to a comfortable temperature for residents within regulation limits. The facility's water temperature measured 104 degrees Fahrenheit in restroom #1 and measured 104.7 degrees Fahrenheit in restroom #2, which is not within the required range of 105 and 120 degrees.

LPA Tamayo observed first aid supplies, a fully- charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Tamayo observed a minimum 2- day supply of perishable food and a minimum 7-day supply of nonperishable food.

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: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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: 02/19/2026
NARRATIVE
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LPA observed a locked cabinet for the storage of medication. LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives. Medicine lock box in the refrigerator was locked and inaccessible to residents in care. LPA also observed some electrical outlets thought the home were loose and there is a toilet paper/towel holder in disrepair in bathroom #2. LPA observed the trash bins were emptied out. S3 stated the trash is taken out everyday 1-2 times per day.

The exterior of the building was inspected by the LPA. LPA observed a pool in the back yard that is fully enclosed by fencing that meets regulations and is inaccessible to residents without supervision, the yard was completely fenced in. LPA observed broken glass piled on the ground, S3 did not know where it was from nor the plan for disposal. Facility will ensure to have someone remove the pile of shards by end of day. There was also a sitting area for residents in the backyard. LPA observed there is one chair that is in need of repair or disposal.

LPA observed lunch was provided for 4 of 5 residents, it was a turkey sandwich. 1 out 1 resident did not have lunch due to there not being a vegetarian or diabetic appropriate option. LPA observed S3 prepare chicken which will be used for dinner and an alternative option with vegetables and tofu will be offered. At around 3:00PM LPA observed groceries were delivered.

LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. The posted LIC 500 did not list S3. LPA provided guidance on ensuring LIC 500 is updated each time there is a staffing change. LPA reviewed 3 staff records and 5 resident records. Administrator certificate # 7027423740 and it expires 8/8/26.
LPA provided guidance regarding Administrator oversight.
LPA requested the following documents:
LIC 500: Personnel Report , received
LIC 308: Designation of Administrative Responsibility, received
LIC 402: Surety Bond, if applicable
LIC 610E: Emergency Disaster Plan, received
LIC 309: (for any LLC or Corp) if applicable
Copy of Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S3 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2026 06:59 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 02/19/2026 at 03:07 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: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation) (interview) (record review, the licensee did not comply with the section cited above in due to water being under 105 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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By POC due date the water will be adjusted to be within 105-120 degrees F
Type B
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in which there is only one staff scheduled which is not enough to ensure all care needs are being met timely. LPA observed inconsistent meal times and/or missed meals for 1 out of 1 residents during multiple visits poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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By POC due date, licensee will ensure facility shall employ, and the administrator shall schedule, a sufficient number of staff members to ensure all resident needs are being met including consistent meal times.
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: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 19
Document Has Been Signed on 02/19/2026 06:59 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 02/19/2026 at 03:07 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: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(7)
General Food Service Requirements
(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring there are diabetic and or vegetarian options available at each meal time. LPA observed only turkey sandwitches were prepared for residents and 1 of 1 resident ate their own snacks/food due to not having an option available to them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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By POC due date, licensee will submit a plan to ensure nutricious modified diets are provided at each meal time and that meal times stay consistent.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in which records including incident reports, discharge paper work, complete LIC 601, and the most updated LIC 602 is avialble for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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By POC due date, licensee will ensure all resident records are completed, up to date, and all fields are filled out.
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: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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