Golden Heritage Senior Care

Allegation investigated: 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.

icensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with direct care staff, and explained the purpose of the visit. LPA Valerio spoke to Administrator Yelena who gave permission for staff on shift to sign on her behalf. LPA Valerio read the report to Administrator via cell phone. The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility. Allegation: The facility allowed excluded individuals to work in the facility. On 02/19/2026, LPA Valerio conducted an unannounced visit. LPA Valerio did not see excluded individual 1 (EI-1) or excluded individual 2 (EI-2) present in the facility. Continues on LIC 9099 - C... Unsubstantiated LPA Valerio interviewed facility staff. Facility staff denied ever seeing EI-1 or EI-2 in the facility. LPA Valerio interviewed Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), Resident 5 (R5), and Resident 6 (R6). Residents were shown pictures of EI-1 and EI-2 and asked if they have seen the individuals or know their names. R1 did not recognize the people in the pictures. R2's interview was unsuccessful and could not confirm or deny any information. R3 denied ever seeing the individuals and stated R3 did not know them. R4 stated R4 has seen EI-1 and EI - 2 at the grocery store before. LPA asked if R4 seen them at the facility, R4 stated no. LPA asked the names of the people in the picture. The names provided by R4 did not match the names of the individuals. R5 stated R5 does not know the individuals in the picture and R5 is glad to be aware that they are not allowed to be at the facility. R6 was unaware of the individuals in the photo and has not seen them before. Allegation: Staff are forging resident documents On 02/19/2026, LPA Valerio obtained LIC 602 Physician Reports for R1 - R6. LPA Valerio contacted the physician and/or health center documented on the LIC 602. LPA was unable to confirm validity for R1's LIC 602. LPA was able to confirm the validity of the doctors signature for R2's LIC 602. LPA was able to confirm the validity of the doctors signature for R3's LIC 602. LPA was unable to confirm validity for R4's LIC 602. LPA Valerio could not confirm or deny the signature for R5's LIC 602 due to the number being out of service. LPA was able to confirm the validity of the doctors signature for R6's LIC 602. Allegation: The Administrator is not present at the facility for a sufficient amount of time. Staff 1 stated Administrator Yelena comes every week and will come for one or few hours. If staff need additional assistance, Administrator Yelena will come to the facility. R1 stated the administrator comes every week. R2's interview was unsuccessful and could not confirm or deny any information. R3 stated R3 does not know who Yelena is. R4 stated R4 did not know who Yelena is. R5 knows Administrator Yelena comes to the facility every week, but cannot recall exact days and times. R6 knows Administrator Yelena comes to the facility every week and stated "She comes when she comes." Continues on LIC 9099 - C, page 3... Yelena stated she is at the facility at least twenty (20) hours per week. She stated that it varies, honestly. She stated it can be more or less depending on which facility needs me more. According to the LIC 500, Administrator Yelena is at the facility every Monday, Tuesday, Wednesday, Thursday and Friday from 8:00 AM to 12:00 PM. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held with Administrator Yelena via cell, and a copy of report was left at the facility with facility staff.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 27-AS-20260211122308

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio met with Facility Staff Siteri and explained the purpose of the visit. LPA Valerio and staff toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed three (3) resident bedrooms. Resident bedrooms were fully furnished and free from odors. Resident bathrooms were observed to be fully stocked with hygiene supplies, such as paper towels, toilet paper, and hand soap. LPA Valerio observed additional hygiene supplies locked in a cabinet available for use. LPA Valerio observed medications, sharps, and toxins locked an inaccessible to residents in care. LPA Valerio observed an outside contractor painting the kitchen area and replacing the lights. The facility was observed to have an adequate food supply. LPA Valerio observed snacks accessible to the residents located near the kitchen area and dinning room. The exterior area was observed to have a large area for outdoor visitation and/or activities. LPA Valerio observed residents watching television in their room/living room, smoking outside in the backyard, and walking in the back yard. Staff was observed assisting with resident ADLs, cleaning, and assisting the contractor. LPA Valerio observed the fire extinguisher was fully charged with last annual service date of 09 of 2025. LPA Valerio spoke to staff and residents during the visit. LPA Valerio observed alarms to be in working condition. LPA Valerio reviewed staff and resident files. All files were observed to up to date with required documentation. LPA Valerio requested the following be sent to cclascpsacramentosouthRO@dss.ca.gov: LIC 500, LIC 308, LIC 610D, and copy of liability insurance Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed during today's visit. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. Bigelow said that caregiver Siteri Senitirau could sign this report in her absence. LPA Moleski explained to Bigelow that a staff person (S1) had been subject to immediate orders of exclusion, which bars them from working, residing in, or being present in any facility licensed by the California Department of Social Services. Bigelow said that S1 had not worked at this facility since last year. LPA Moleski asked Bigelow to remove S1 from this facility's Guardian roster. Bigelow agreed to do so. An exit interview was held with Senitirau. A copy of this report, and a copy of the immediate exclusion orders, were left with Senitirau.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski texted facility administrator Lyenna Bigelow and explained the purpose of the visit. Bigelow said staff member Siteri Senitirau could sign this report. During this visit, LPA Moleski took scans from a resident's file (R1) and interviewed a staff member (S1). No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Senitirau.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). R2 was identified as bedridden on their latest LIC 602, dated 02/07/2025. Comments on the LIC 602 describe the resident as "bed bound," and suffering from motor impairment or paralysis. R2's latest appraisal, dated 02/18/2025, indicated that R2 was in bed all the time. In an interview during this visit, S1 referred to R2 as "bed bound." This facility has a fire clearance for six non-ambulatory residents, but is not cleared to accept or retain any bedridden residents. Medical records from an emergency room visit on 2/24/25 indicate that R3 received a CT scan of their head due to a "fall/ qeustionable [sic.] head injury." The CT scan revealed no internal bleeding or other signs of serious injury. LPA Moleski reviewed fax and email records and observed that no incident reports were received regarding this fall. LPA Moleski observed that three residents' admission agreements (R3, admitted 1/27/25, R4, admitted 2/10/25, and R6, admitted 3/14/25) did not include base rates for basic services. LPA Moleski toured the facility 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 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. [continued on 809-C] The facility's water temperature was tested and measured 103 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. While touring the facility, LPA Moleski observed that the interior garage door was unlocked. LPA Moleski observed many cleaning solutions and chemicals out in the garage. A cabinet labeled "keep locked when not in use" and "must be locked at all times" was unlocked. Several different cleaning solutions were observed inside the unlocked cabinet. LPA Moleski observed one resident (R6) walk into the garage unaccompanied during this visit. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S1). Residents were not able to be interviewed during this visit. This facility is cited per 22 CCR Sections 87202(a)(2), 87309(a), 87211(a)(1), 87303(e)(2) and 87507(g)(3)(A). Due to a violation of fire clearance requirements, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with staff member Siteri Senitirau.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). R2 was identified as bedridden on their latest LIC 602, dated 02/07/2025. Comments on the LIC 602 describe the resident as "bed bound," and suffering from motor impairment or paralysis. R2's latest appraisal, dated 02/18/2025, indicated that R2 was in bed all the time. In an interview during this visit, S1 referred to R2 as "bed bound." This facility has a fire clearance for six non-ambulatory residents, but is not cleared to accept or retain any bedridden residents. Medical records from an emergency room visit on 2/24/25 indicate that R3 received a CT scan of their head due to a "fall/ qeustionable [sic.] head injury." The CT scan revealed no internal bleeding or other signs of serious injury. LPA Moleski reviewed fax and email records and observed that no incident reports were received regarding this fall. LPA Moleski observed that three residents' admission agreements (R3, admitted 1/27/25, R4, admitted 2/10/25, and R6, admitted 3/14/25) did not include base rates for basic services. LPA Moleski toured the facility 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 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. [continued on 809-C] The facility's water temperature was tested and measured 103 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. While touring the facility, LPA Moleski observed that the interior garage door was unlocked. LPA Moleski observed many cleaning solutions and chemicals out in the garage. A cabinet labeled "keep locked when not in use" and "must be locked at all times" was unlocked. Several different cleaning solutions were observed inside the unlocked cabinet. LPA Moleski observed one resident (R6) walk into the garage unaccompanied during this visit. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S1). Residents were not able to be interviewed during this visit. This facility is cited per 22 CCR Sections 87202(a)(2), 87309(a), 87211(a)(1), 87303(e)(2) and 87507(g)(3)(A). Due to a violation of fire clearance requirements, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with staff member Siteri Senitirau.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. Bigelow said caregiver Lesi Buinimasi could sign this report in her absence. This visit is to confirm immediate exclusion orders for a staff member (S1). Bigelow acknowledged that S1 is excluded effective immediately, which means that S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders this facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Bigelow said that S1 has not been working at this facility since at least 2023. Bigelow agreed to remove S1 from all facility Guardian rosters as soon as possible. No deficiencies were cited during this visit. An exit interview was held with Bigelow. A copy of this report and the immediate exclusion notice were left with Buinimasi. A signature on this report acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit. Upon arrival, two staff members were present (S1-S2). LPA Moleski reviewed Guardian records and observed that S2 was not associated to this facility. S2 told LPA Moleski that S2 had started working at this facility today. Bigelow associated S2 during this visit. LPA Moleski reviewed six resident files (R1-R6) and five staff files (S1-S5). LPA Moleski toured the facility with staff 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 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. [continued on 809-C] LPA Moleski interviewed two staff members (S1-S2) and one resident (R6). This facility hereby cited per 22 CCR Section 87355(e)(2). This facility was previously cited per 22 CCR Section 87355(e)(2) on 4/24/24. A $1,000 civil penalty is hereby assessed, as this is a repeat violation. A civil penalty in the amount of $100 per day for one day is hereby assessed for one day worked by a caregiver not associated to this facility (S2). An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with Bigelow.the state’s words, verbatim · CDSS document, May 6, 2024

Allegation investigated: Staff pushed resident.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Bigelow, a staff member (S1) and four residents (R1, R2, R3, R6). During an interview, Bigelow said that a resident (R1) had been experiencing unusual behaviors during the time period of March 2, 2024 through March 4, 2024. Bigelow said during this time period, R1 had poured water all over the facility’s floors, was urinating in the facility, and on March 4, splashed water on S1. Afterward, R1 claimed that S1 had pinned R1 on the floor, according to Bigelow. Bigelow said R1 was diagnosed with a urinary tract infection after being sent out to the hospital. [continued on 9099-C] Unsubstantiated During an interview, LPA Moleski asked R1 about the events on March 4, 2024. R1 said there was “water everywhere.” R1 said that S1 had pushed R1, but also said that R1 had fallen. LPA Moleski did not observe any unusual injuries on R1 during this interview which would indicate physical abuse. LPA Moleski reviewed R1’s file. R1 is diagnosed with bipolar disorder, but does not have dementia, according to R1’s LIC 602 dated 1/18/24. During an interview, S1 said that R1 splashed water on S1 on March 2, 2024, then did so again on March 4, 2024. S1 said that after this second incident, R1 grabbed a plate and raised it to strike S1. S1 said S1 grabbed R1’s wrist and removed the plate from R1’s hand, but did not push R1. S1 said R1 had not fallen during the incident. S1 said the incident occurred in the facility’s living room, but said no others were present to witness the events as described. S1 said police were called and R1 was later sent out to the hospital. In interviews, R2, R3, and R6 did not report having been physically abused by staff while living at the facility. The department has determined the following as it relates to the allegation that staff pushed a resident: Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Bigelow.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 27-AS-20240304171144

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a complaint investigation. However, upon arrival, LPA Moleski observed multiple deficiencies. LPA Moleski met with facility administrator Yelena Bigelow and explained the purpose of the visit. Shortly after LPA Moleski had parked his car, around 9 a.m., LPA Moleski observed a resident (R1) walking toward the facility from the community. LPA Moleski observed R1 round a corner from elsewhere in the community and walk to the facility, and enter the backyard through a side gate. R1 was unassisted while out in the community. LPA Moleski entered the facility shortly after R1 and was met by a staff member (S1). S1 provided their name and birth date to LPA Moleski. LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility. S1 said this was their first day at this facility. LPA Moleski reviewed R1's file and observed that R1 is not able to leave the facility unassisted. LPA Moleski asked S1 if S1 was aware that R1 had taken a walk. S1 said they were not aware. LPA Moleski interviewed R1, who said that R1 had taken a walk to search for cigarette butts. LPA Moleski and Bigelow observed that the alarm on the sliding door into the backyard was not turned on. This facility is hereby cited per 22 CCR Section 87411(a) and 87355(e)(2). This facility was previously cited per 22 CCR Section 87411(a) on 11/9/23 due to a previous AWOL by R1. As this is a repeat citation, a civil penalty in the amount of $1,000 is hereby assessed. An additional civil penalty of $100 is hereby assessed for one day worked by S1 while not associated to this facility. An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with Bigelow.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 25, 2024

"(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services." This requirement was not met as evidenced by: Based on observation and record review, R1 was in the community unattended, despite being unable to do so per doctor's orders, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee agrees to provide R1 with cigarettes to prevent his elopements, and to install an alarm on the backyard side gate. Additionally, licensee agrees to ensure that all other alarms are regularly checked for functionality. Licensee shall provide LPA Moleski a written plan describing how the above will be accomplished by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Apr 25, 2024

"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ... (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ..." This requirement was not met as evidenced by: Based on observation and record review, S1 worked in this facility without criminal record association, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee agrees to submit transfer requests for all unassociated staff by POC due date. Licensee shall cc LPA Moleski on all electronic communication with transfer request staff. sacasctransferrequest@dss.ca.gov