<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701690
Report Date: 03/10/2026
Date Signed: 03/10/2026 01:07:49 PM

Substantiated


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
01/02/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260102093857
FACILITY NAME:GOLDEN RESIDENCE SENIOR CARE IIFACILITY NUMBER:
342701690
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:5105 VILLAGE WOOD DRTELEPHONE:
(916) 840-5298
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Merelisoni MataitogaTIME COMPLETED:
01:21 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff locks the front gate
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint investigation. LPA Lee met with care staff Merelisoni Mataitoga and explained the purpose of the visit. LPA Lee requested that care staff Mataitoga contact and inform Administrator Tevita Kaloulasulasu that Community Care Licensing Division (CCLD) staff, LPA Lee, was present at the facility.

A brief interview was conducted with Administrator Kaloulasulasu by phone, during which the administrator stated that LPA Lee could continue the visit with care staff Mataitoga and sign the necessary documents. LPA Lee also explained the purpose of the visit and reviewed the complaint findings with Administrator Kaloulasulasu. The current census is 5.

It was alleged that staff lock the front gate. During the course of the investigation, it was learned through interviews with care staff (S1) and Administrator Kaloulasulasu that the front gate is secured and locked
CONTINUDED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
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 7
Control Number 27-AS-20260102093857
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 II
FACILITY NUMBER: 342701690
VISIT DATE: 03/10/2026
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
with a padlock at night, typically between 9:00 PM and 10:00 PM, to prevent intruders from entering the facility. Based on these interviews with facility staff, LPA Lee was able to corroborate the allegation that the front gate is locked by staff.

As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Mataitoga and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20260102093857
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 II
FACILITY NUMBER: 342701690
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2026
Section Cited
CCR
87203
1
2
3
4
5
6
7
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to provide LPA Lee with a written declaration stating that no facility staff member will lock the front gate that prevents residents from leaving the facility property and for fire safety.
8
9
10
11
12
13
14
Based on interviews statements with care staff (S1) and Administrator Kaloulasulasu that the front gate is secured and locked with a padlock at night, typically between 9:00 PM and 10:00 PM, to prevent intruders from entering the facility, which poses immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
The declaration will also include a statement confirming that the cited regulation has been reviewed and understood by all facility staff. The Plan of Correction (POC) is due by 03/13/2026 by the end of the day (5:00 PM).

1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
01/02/2026 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260102093857

FACILITY NAME:GOLDEN RESIDENCE SENIOR CARE IIFACILITY NUMBER:
342701690
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:5105 VILLAGE WOOD DRTELEPHONE:
(916) 840-5298
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
03/10/2026
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Merelisoni MataitogaTIME COMPLETED:
01:21 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not answer the phones
Staff do not ensure the residents are served a variety of foods
Staff do not meet resident’s incontinence needs
Staff do not ensure residents personal needs are reassessed as needed
Staff threatened resident
Staff do not meet resident’s personal care needs
Staff did not ensure medications were inaccessible to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint investigation. LPA Lee met with care staff Merelisoni Mataitoga and explained the purpose of the visit. LPA Lee requested that care staff Mataitoga contact and inform Administrator Tevita Kaloulasulasu that Community Care Licensing Division (CCLD) staff, LPA Lee, was present at the facility.

A brief interview was conducted with Administrator Kaloulasulasu by phone, during which the administrator stated that LPA Lee could continue the visit with care staff Mataitoga and sign the necessary documents. LPA Lee also explained the purpose of the visit and reviewed the complaint findings with Administrator Kaloulasulasu. The current census is 5.

It was alleged that staff do not answer the facility phone. This investigation included interviews with residents and staff and observations.
CONTINUED LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20260102093857
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 II
FACILITY NUMBER: 342701690
VISIT DATE: 03/10/2026
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
 LPA Lee interviewed five out of five residents, who stated they have no concerns regarding the facility phone. It was also learned that some residents have their own cell phones and primarily communicate with family members using their personal phones rather than the facility phone. Based on interviews with residents and staff, it was reported that residents had been informed that the facility phone was temporarily not working due to issues with the cable service. The facility had reported the issue to the service provider and informed residents that they could use the staff member’s cell phone if needed while the service was under maintenance. The complainant also stated they were unaware that there had been a change of ownership and had been calling the previous phone number associated with Abounding Love III. The complainant was not aware that a new phone number had been established under the new ownership. During observations conducted on 01/08/2026 and 03/10/2026, LPA Lee observed a house phone located in both the kitchen and the staff room. On 03/10/2026 it was observed that the phone is in good repair. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

It was alleged that staff do not ensure residents are served a variety of foods. This investigation included interviews with residents and staff, as well as observations. LPA Lee interviewed four out of five residents, who stated they have no concerns regarding the food being served. Resident 1 (R1) stated that the “food is good,” but also mentioned that the facility has “limited variety.” Interviews with facility staff denied the allegation and stated that they do provide a variety of foods to residents in care. Based on observations conducted on 01/08/2026, LPA Lee observed the following items being served for breakfast: scrambled eggs, strawberries, sausage, waffles, and coffee. For lunch, LPA Lee observed hamburgers, fries, oranges, apples, water, soda, beef patties, lettuce, mushrooms, tomatoes, and onions being served. During 03/10/2026 visit, LPA Lee also observed a variety of food being served for breakfast and lunch. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

It was alleged that staff do not meet residents’ incontinence needs and staff do not ensure residents’ personal needs are being reassessed as needed.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20260102093857
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 II
FACILITY NUMBER: 342701690
VISIT DATE: 03/10/2026
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
This investigation included interviews with residents and staff, a review of records, and observations. LPA Lee interviewed five out of five residents, who stated they have no concerns regarding their incontinence needs not being met and and four out of the five reported that they are able to manage their own care. (R1) stated that they do not require assistance with incontinence care and is able to manage it independently. Facility staff interviewed denied the allegation and stated that two residents require assistance with incontinence care and that staff regularly change the residents’ incontinence briefs. Based on records reviewed, R1’s Physician’s Report dated 02/03/2026 and Needs and Services Plan indicate that R1 does not have bowel or bladder incontinence and is able to perform activities of daily living independently, with the exception of medication management. During facility visits on 01/08/2026 and 03/10/2026, LPA Lee did not observe any incontinence odors in the facility. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

It was alleged that staff threatened residents. This investigation included interviews with residents and staff, as well as a review of records. LPA Lee interviewed five out of five residents, all of whom denied being yelled at or threatened by staff and stated that they had not observed staff yelling at or threatening other residents. R1 also denied being threatened by facility staff, reported no concerns, and stated that they feel safe living in the facility. Facility staff were interviewed and denied the allegations. During the investigation, it was also learned that R1 had been smoking in their room, which is against the facility’s house rules. Staff reminded R1 that the designated smoking area is located in the courtyard and reported that R1 had been redirected on two separate occasions. Staff also explained to R1 that failure to follow house rules could result in eviction, as smoking inside the room poses a fire safety risk to all residents in the home. A review of R1’s admission agreement confirmed that smoking is not permitted inside the premises and is only allowed in designated outdoor areas. House rules were also reviewed up admission and posted in the facility. Since that discussion, R1 has stopped smoking in their room. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20260102093857
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 II
FACILITY NUMBER: 342701690
VISIT DATE: 03/10/2026
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
It was alleged that staff do not meet residents’ personal care needs. This investigation included interviews with residents and staff, observations, and a review of records. LPA Lee interviewed five out of five residents, all of whom denied that staff do not meet their personal care needs. R1 stated that they receive assistance with hygiene when needed. During LPA Lee’s visit to the facility on 01/08/2026 and 03/10/2026, all residents were observed to be clean and groomed. On 01/08/2026, R1 was observed to have long hair and a beard. R1 stated that they preferred to keep their hair and beard long and did not wish to have them cut. R1’s fingernails and toenails were also observed and were not overgrown. During a facility visit on 03/10/2026, R1 was observed to be clean and well-groomed. R1 no longer had long hair or a beard, and it was learned that R1 had decided to have them cut. Additionally, R1’s toenails were observed and were not overgrown. R1 reported that they are able to trim their own toenails, and when assistance is needed, facility staff will provide support. R1 also stated that they have no concerns and confirmed that they receive assistance with personal care when necessary. A review of R1’s LIC 602 Physician’s Report and Needs and Services Plan indicates that R1 is able to provide their own self-care, including bathing, grooming, and managing their own toileting needs. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

It was alleged that staff did not ensure medications were inaccessible to residents. This investigation included interviews with residents and staff, as well as observations. LPA Lee interviewed five out of five residents, all of whom stated that they do not keep medications in their rooms and that facility staff securely store them in a locked cabinet. Residents also confirmed that they receive their medications from staff. Facility staff denied the allegations and stated that all residents’ medications are stored in a locked, secure area designated for that purpose. During visits on 01/08/2026 and 03/10/2026, LPA Lee observed that no medications were present in residents’ rooms and that all medications were securely stored in the entry closet, making them inaccessible to residents. Additionally, it was reported that the concerns by the complainant were related to the previous licensee prior to the change of ownership. Based on interviews, records review, and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation.

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.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7