Golden Heritage Senior Care III

Type of visit: Required - 1 Year

On XX at XX Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Heritage Senior Care III for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Eliese Qioele and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed a large branch from a tree has broke/fallen and is leaning against the home/fencing and must be removed. LPA measured the water temperature, temperature measured at 117 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 7, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: ) The facility allowed excluded individuals to work in the facility. 2) Staff are forging resident documents. 3) The Administrator is not present at the facility for a sufficient amount of time.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Golden Heritage Senior Care III (RCFE) on 7/17/26 at 1:40pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Eliese Qioele and together discussed the investigation details. Based on files obtained and reviewed during the investigation process, LPA Gould was unable to corroborate the allegation. LPA reviewed 4 resident files. LPA requested and obtained physician reports (LIC 602) for all 6 residents in care (see confidential name list LIC-811 dated 7/17/26). LPA Gould reviewed reports for each resident. Upon review, the department has no concerns for five of the six physician reports are being altered or fraudulent. The files reviewed appear to be completed by the resident’s physician or an appropriately skilled professional that are able to complete the forms per department regulations. Report Continued on LIC 9099-C Unsubstantiated Additionally, LPA conducted interviews with two staff members and three residents. All staff interviewed denied excluded individuals presence at the facility and had knowledge they are not allowed at any licensed facility. The three residents interviewed denied witnessing any individuals identified in the complaint as being present at the facility or did not recognize photos of the identified individuals. All staff interviewed knows who the administrator is. All three residents interviewed were able to identify who the facility administrator is and identified her most recent working date. All residents interviewed identified the administrator present on a regular basis. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 27-AS-20260211114643

Allegation investigated: Facility staff abandoned resident at hospital.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on February 26, 2026, at 2:46 PM to deliver complaint findings, LPA Martinez met with Eliesa Qiolele, and explained the purpose of the visit. Confidential interviews were conducted with four individuals during the period of January 28, 2026, to February 26, 2026. Based on interviews conducted and records reviewed, it was determined that the facility did follow the required eviction procedures. It was learned the facility did not provide R1 a 30-day eviction notice. In addition, R1 was not allowed to return to the facility after being discharged from the hospital. LPA Martinez observed R1's belongings in the living room common area on January 28, 2026. Moreover, R1's room was occupied by resident 2 (R2). Continued... Substantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. LPA Martinez also conducted a phone interview with the Licensee during today's visit and worked on POC plan with the licensee. The Administrator was not present at the facility during today's visit.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 27-AS-20260122112616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Mar 19, 2026

87224(a): Eviction Procedures: The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidence by: based on file review and interviews, the Licensee did not ensure that a 30 day eviction notice was given to R1 prior to evicting them from the facility. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: Licensee agrees that the Administrator will be trained on eviction procedures and regulation by a third party trainer by POC Date March 19, 2026. Licensee agrees to email training document to LPA Martinez on March 19, 2026, by 5:00 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on February 26, 2026, at 2:00 PM to conduct a case management visit. LPA Martinez met with Eliesa Qiolele and explained the purpose of the visit. The purpose of the visit today, is in response to an Administrator Qualification deficiency. The Administrator did not follow the eviction regulation. Due to the Administrator not following the proper eviction regulation and procedures, resident 1 (R1) was displaced and abandoned at a hospital. As a result of this incident, the Administrator does not have the knowledge or ability to conform to the applicable laws, rules and regulations. The facility will be cited under Administrator Qualifications and Duties 87405(d)(2). The Deficiency can be found on the 809D Page. An exit interview was conducted, and a copy of this 809 report, 809D- Page, and Appeals Rights were provided to facility staff Eliesa Qiolele. LPA Martinez also conducted a phone interview with the Licensee during today's visit and worked on the POC plan with the licensee. The Administrator was not present at the facility during today's visit.the state’s words, verbatim · CDSS document, Feb 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Mar 19, 2026

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). Knowledge of and ability to conform to the applicable laws, rules and regulations...This was not met as evidence by: Based on interviews record reviews, and observation, the Licensee did not ensure the facility Administrator conformed to the eviction regulation and to the applicable laws, rules and regulations. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Feb 26, 2026

Plan of correction: The Licensee agrees to provide LPA Martinez the current Administrator's education documentation and work experience, conduct a work performance audit. The Licensee agrees to email LPA Martinez the Administrator's work schedule and work performance audit by POC Date March 19, 2026, by 5:00 PM.

Type of visit: Case Management - Incident

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on January 28, 2026. at 9:15 AM. LPA Martinez met with Eliesa Qiolele and explain the purpose of the visit. The purpose of the visit is to follow up on an incident report received on January 22, 2026. LPA Martinez obtained resident 1's facility records and medical records. LPA Martinez will return to the facility at a later date to follow up on this incident. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Post Licensing

On 11/3/2025 at 11:50 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced Post Licensing inspection. LPA Hughes met with licensee Yelena Bigelow. The current census is 6 with 1 facility staff. This facility is a single story building licensed to serve (6) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair, however LPA observed the facility not free of pest. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 120.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 03/08/2025. LPA observed the facility has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 6 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 6 out of 6 resident files and they were complete. LPA reviewed 2 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. As a result of this visit, the facility is not in compliance with Title 22 Regulations, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Yelena and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Prelicensing

On 6/26/25 at 1:20pm Licensing Program Analyst (LPA) Kevin Gould conducted a follow up Pre-Licensing inspection to ensure all items have been corrected and the facility is ready to be licensed. LPA observed all corrections have been made. The departments only outstanding item to be completed is an updated fire clearance approval for one bedridden resident. Applicant is currently in communication and providing updated documents to CAB. LPA requested an updated LIC 999 (facility sketch) on behalf of CAB. Once the updated fire clearance is approved LPA has no objections to the facility being licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Prelicensing

On 6196/25 at 1:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Change of Ownership Inspection. LPA met with the staff and discussed LPA observations and corrections that must be completed prior to the facility being approved for a license. LPA observed the following corrections: Hot water temperature was recorded at 116 degrees F. Sharp knives and cleaning supplies are secured and inaccessible to residents. medications locked and inaccessible to residents. Facility has an adequate non-parishable food supply lock removed from kitchen fridge. broken hutch in bedroom #3 (broken glass) has been removed broken patio chairs and patio umbrella removed. lights not functioning throughout the facility. All light fixtures must be operable. The Following corrections are still required to be approved for a license. missing handle on sliding door emergency exit next to dining area. replace/repair multiple screen doors. fix/replace closet door in bedroom #4. repair/replace curtain rod bedroom #1 One bedridden resident is present and applicant does not have a fire clearance for bedridden residents. This facility has not met all requirements to be licensed at this time. All corrections and plans of corrections must be completed prior to the department approving the facility to be licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Prelicensing

On 6/6/25 at 10:00am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Change of Ownership Inspection. LPA met with the applicant and discussed LPA observations and corrections that must be completed prior to the facility being approved for a license. LPA observed the following deficiencies: Hot water temperature was recorded at 126 degrees F. Sharp knives and cleaning supplies unsecured and accessible to residents. medications not locked and inaccessible to residents. LPA observed rodent activity including droppings and chewed through food storage. Facility did not have an adequate non-parishable food supply - expired foods. lights not functioning throughout the facility. All light fixtures must be operable. remove lock from kitchen fridge. missing handle on sliding door emergency exit. replace/repair multiple screen doors. fix/replace closet door in bedroom #4. repair/replace curtain rod bedrooms 3 &1 discard broken hutch in bedroom #3 (broken glass) repair/replace floor boards in bedroom 1 and any other areas in the home. remove/replace broken patio chairs. remove/replace broken patio umbrella secured with pile of broken concrete. Staff members require annual training documentation. One bedridden resident is present and applicant does not have a fire clearance for bedridden residents. This facility has not met all requirements to be licensed at this time. All corrections and plans of corrections must be completed prior to the department approving the facility to be licensed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 6, 2025

The state marks this report as 12 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 6/6/25 LPA conducted Component III orientation with applicant. This facility has not met all requirement to be licensed at this time. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 6, 2025

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 6 Census (if any clients in care): 3 COMP II Participants: Yelena Bigelow, Applicant Aliti Waqalala, Administrator Interview Method: Virtual interview (Microsoft Teams) On June 5, 2025, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License Type, Client/Resident Populations, and Program. 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readinessthe state’s words, verbatim · CDSS document, Jun 5, 2025