342701682-7-27-2026-27-AS-SRIN-DWXTWA-20260814150514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701682
Report Date: 07/27/2026
Date Signed: 07/27/2026 02:25:11 PM

Unsubstantiated

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
02/11/2026 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260211112435

FACILITY NAME:	GOLDEN RESIDENCE SENIOR CARE		FACILITY NUMBER:	342701682
ADMINISTRATOR:	KALOULASULASU, TEVITA		FACILITY TYPE:	740
ADDRESS:	27 TRISTAN CIR		TELEPHONE:	(916) 619-8590
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 6	DATE:	07/27/2026
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Tevita Kaloulasulasu		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
The Administrator is not present at the facility for a sufficient amount of time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 07/27/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to the facility. Upon arrival, the LPA Lee met with Administrator Tevita Kaloulasulasu and explained the purpose of the visit. The purpose of the visit was to deliver the findings related to the allegations above. At the time of the visit, the facility census was six.

It was alleged that the facility allowed excluded individuals to work at the facility. This investigation consisted of interviews with Administrator Tevita Kaloulasulasu and residents, as well as a review of records and observations. On 2/17/2026, LPA Lee conducted a visit to the facility and interviewed Administrator Kaloulasulasu, who stated he has not seen excluded individuals E1 or E2 in the facility since the change of ownership in July 2025. The Administrator Kaloulasulasu also reported that, since assuming ownership of the facility, the excluded individuals have not been to the facility and that they would not permit any excluded individuals on the premises.
Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026

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 3

Control Number 27-AS-20260211112435

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: GOLDEN RESIDENCE SENIOR CARE	FACILITY NUMBER: 342701682
	VISIT DATE: 07/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with six of six residents indicated that they had not observed the excluded individuals in the facility. LPA Lee reviewed the LIC 500 Personnel Report and the Guardian background check system and did not find either excluding individual listed. Additionally, since the change of ownership on 07/07/2025, the Department has conducted five facility visits to the facility, and during those visits, LPA Lee did not observe the excluded individuals on-site. Based on the information obtained, there is insufficient evidence to corroborate the allegation that the facility allowed excluded individuals to work in the facility.

It was alleged that staff were forging resident documents. The investigation included interviews with Administrator Kaloulasulasu and residents, as well as a review of facility records. Administrator Kaloulasulasu denied the allegation, stating that the residents' LIC 602 Physician's Reports were obtained during the change of ownership and that no documents had been altered or falsified. Interviews with six out of six residents stated that facility staff transport them to medical appointments or the hospital when needed. During a facility visit on 02/17/2026, LPA Lee collected the LIC 602 Physician's Reports for all six residents. A review of the records showed that each report was complete and contained a physician's signature. On 03/09/2026, LPA Lee contacted the licensed medical professionals who completed the six LIC 602 Physician's Reports; however, they were unable to verify whether the documents had been forged or falsified. LPA Lee also attempted to verify the authenticity of the physician signatures but was unable to confirm. Based on interviews and the records reviewed, there is insufficient evidence to support the allegation that the facility forged resident documents. Therefore, the allegation is unsubstantiated.

It was alleged that the facility administrator is not present at the facility for a sufficient amount of time. The investigation included interviews with Administrator Kaloulasulasu, resident interviews, a review of facility records, and observations. Administrator Kaloulasulasu denied the allegation, stating that he oversees two facilities and divides his time between them, but remains available by phone when he is not on-site. Six out of the six residents interviewed were able to identify the Administrator by name and stated that he is present at the facility. A review of the facility's LIC 500, Personnel Report, showed that Administrator Kaloulasulasu is scheduled to work at the facility on Mondays, Tuesdays, and Thursdays from 7:00 a.m. to 7:00 p.m. Additionally, since the change of ownership on 07/07/2025, the Department has conducted five facility visits (07/31/2025, 09/09/2025, 10/09/2025, 02/17/2026, and 07/01/2026), and the Administrator was present during each visit.
CONTINUED LIC 9099-C

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20260211112435

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: GOLDEN RESIDENCE SENIOR CARE	FACILITY NUMBER: 342701682
	VISIT DATE: 07/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews, record review, and observations, there is insufficient evidence to support the allegation that the facility Administrator is not present at the facility for a sufficient amount of time. Therefore, the allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Administrator Kaloulasulasu and a copy of this report was provided to the facility.

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3