342701690-10-14-2025-27-AS-PLEE-DMFQ5K-20251014115203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701690
Report Date: 10/14/2025
Date Signed: 10/14/2025 11:52:17 AM

Document Has Been Signed on 10/14/2025 11:52 AM - 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:	GOLDEN RESIDENCE SENIOR CARE II		FACILITY NUMBER:	342701690
ADMINISTRATOR/ DIRECTOR:	KALOULASULASU, TEVITA		FACILITY TYPE:	740
ADDRESS:	5105 VILLAGE WOOD DR		TELEPHONE:	(916) 840-5298
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 6		CENSUS: 6	DATE:	10/14/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:56 AM
MET WITH:	Tevita Kaloulasulasu		TIME VISIT/ INSPECTION COMPLETED:	12:08 PM

NARRATIVE

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On 10/14/2025, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to
conduct a post-licensing inspection. LPA Lee arrived met with administrator Tevita Kaloulasulasu and explained the purpose of the visit. Administrator assisted with today’s visit.

There are currently six (6) residents living at the facility. LPA conducted a tour of the physical plant, both inside and outside, alongside Administrator Kaloulasulasu to assess any health and safety concerns. LPA inspected the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garge and outdoor courtyards to ensure compliance with Title 22 regulations. The facility was observed to be clean, free of odors, and in good repair. Resident bedrooms were appropriately furnished, with adequate bedding and lighting. The hot water temperature was measured at 110.6°F. The indoor temperature was 73°F, which falls within the required range of 68°F to 85°F. LPA observed the facility maintains at least one week’s supply of nonperishable food and two days’ supply of perishable food. The centrally stored medication area was locked and inaccessible to residents. Fire extinguishers and first aid kits were up to date. The fire extinguisher was last service on 11/27/2024. Smoke and carbon monoxide detectors were present and in good working conditions. LPA reviewed files for all six (6) residents and two (2) staff members. All records were complete and contained the required documentation. Staff records confirmed that all individuals requiring caregiver background checks were fingerprint cleared and properly associated with the facility. During today’s visit, LPA was informed by Staff #1 (S1) that Resident #1 (R1) had left the facility during the night.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

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: GOLDEN RESIDENCE SENIOR CARE II	FACILITY NUMBER: 342701690
	VISIT DATE: 10/14/2025

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According to S1, on 10/11/2025, they awoke to find R1 missing and then filed a missing person report with the local police department. Later that same day, the police informed S1 that R1 was not missing but had been arrested for attempting to break into a nearby residence. S1 reported that a neighbor had contacted them and explained that R1 was caught trying to enter their home at approximately 1:00 AM, prompting the neighbor to call law enforcement. Per R1’s LIC 602 Physician’s Report, R1 is able to leave the facility unassisted; however, per the physician’s report it also says that R1 has mild cognitive impairment. S1 stated that R1 was last seen at around 10:00 PM watching television. S1 then went to bed at approximately 11:00 PM. S1 also noted that they work from 7:00 AM to 7:00 PM and require rest, and that they were the only staff members on duty that night and into the following day. Additionally, S1 reported that the facility’s door alarm is always active; however, R1 is aware of how to disable the alarm system.

As a result of this post-licensing the facility is not in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Kaloulasulasu and a copy of these LIC 809 reports, LIC 809-D and appeal rights along were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2025 11:52 AM - It Cannot Be Edited

Created By: Pang Lee On 10/14/2025 at 11:30 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: GOLDEN RESIDENCE SENIOR CARE II	FACILITY NUMBER: 342701690
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87464(d)

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with staff they didn’t know the whereabout of a resident who left the facility at approximately 1:00 AM and got arrested for trying to break into a neighbor’s house. Per the residents’ LIC 602 residents can leave unassisted; however, the residents have a mild cognitive impairment, which poses an immediate health, safety risk to residents in care.
	POC Due Date: 10/24/2025
	Plan of Correction
1 2 3 4	The administrator along with care staff will review the regulation cited today. All staff are to be aware of their resident’s whereabouts at all times and meet their needs at all times regardless of if they can leave the facility unassisted. Administrator will conduct Basic Services training and provide LPA Lee training materials used along with staff sign in sheet by POC due date 10/24/2025 end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Pang Lee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC809 (FAS) - (06/04)

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