Golden Residence Senior Care II

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.

On 07/027/2026, 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. The investigation consisted of interviews with facility staff and residents, as well as a review of facility records and observations. On 02/17/2026, LPA Lee conducted a facility visit and interviewed staff 1 (S1), who stated they had not seen excluded individuals E1 or E2 at the facility since the change of ownership in July 2025. Administrator Kaloulasulasu also denied the allegation, stating that the excluded individuals have not been at the facility since he assumed ownership and that they would not be permitted on the premises. CONTINUED LIC 9099-C Unsubstantiated Four of the four residents interviewed stated they had not observed the excluded individuals at the facility. Two additional residents declined to be interviewed. LPA Lee reviewed the facility's LIC 500, Personnel Report, and the Guardian background check system and found that neither excluded individual was listed as facility personnel. Additionally, since the change of ownership on 07/07/2025, the Department has conducted six visits to the facility, during which LPA Lee did not observe either excluded individual on-site. Based on interviews, record reviews, and observations, there is insufficient evidence to support the allegation that the facility allowed excluded individuals to work at the facility. Therefore, the allegation is unsubstantiated. It was alleged that staff were forging resident documents. The investigation included interviews with facility staff and residents, as well as a review of facility records. During interviews, S1 and 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. Four of the four residents interviewed 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 residents LIC 602 Physician's Reports for six residents. A review of the records showed that all six reports were complete and contained physician signatures. On 03/18/2026, LPA Lee contacted the licensed medical professionals who completed the six residents' 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 consisted of interviews with facility staff and residents, as well as a review of facility records and observations. S1 denied the allegation, stating that Administrator Kaloulasulasu oversees two facilities and divides his time between them. S1 reported that when the Administrator is not on-site, he remains available by phone and that S1 has no concern regarding the Administrator's availability. S1 further stated that Administrator Kaloulasulasu is present at the facility approximately two to three times per week. CONTINUED LIC 9099-C Four of the four residents interviewed were able to identify Administrator Kaloulasulasu and S1 by name, indicating they were familiar with both staff members. The residents also stated that the Administrator is present at the facility approximately two to four times per week. Two additional residents declined to be interviewed. A review of the facility's LIC 500, Personnel Report, showed that Administrator Kaloulasulasu is scheduled to work at the facility on Wednesdays, Fridays, and Saturdays from 7:00 a.m. to 7:00 p.m. Additionally, since the change of ownership on 07/07/2025, the Department has conducted six facility visits (08/28/2025, 10/14/2025, 03/10/2026, 01/08/2026, 02/17/2026 and 07/08/2026). The Administrator was present during three of those visits (10/14/2025, 01/08/2028 and 07/08/2026). The remaining three visits when the Administrator was not present occurred on Tuesday and Thursday, which are not days he is scheduled to work at the facility according to the LIC 500 Personnel Report. 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 Kaloulasulasuand a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 27-AS-20260211113537

Type of visit: Required - 1 Year

On 07/08/2026, Licensing Program Analysts (LPAs) Pang Lee, Reza Jamaly, and Kimberly Kulich arrived at Golden Residence Senior Care II (RCFE) to conduct a required annual inspection. Upon arrival, LPAs met with Care Staff Merelisoni Mataitoga and requested that the Administrator, Tevita Kaloulasulasu, be notified that representatives from the Community Care Licensing Division were on site. Administrator Kaloulasulasu arrived shortly thereafter and accompanied LPAs throughout the inspection. LPAsAdmi, care staff Mataitoga and Administrator Kaloulasulasu conducted a tour of the physical plant to evaluate the facility's compliance with health and safety requirements. Upon entering the facility, LPAs observed two fire doors leading to resident bedrooms being propped open. During an interview, Staff 1 (S1) stated that the doors are "always open." LPA Lee advised the Administrator Kaloulasulasu and care staff Mataitoga that the fire doors must remain closed at all times and may not be routinely propped open. Areas inspected included, but were not limited to, the kitchen, resident bedrooms, resident bathrooms, living room, dining room, and outdoor areas. LPAs observed that the facility was not free of odors. Hallway No. 1, leading to the residents’ bedrooms, had a noticeable odor of incontinence. Upon entering Resident Bedroom #3, the odor of incontinence was stronger. LPAs also observed Care Staff Mataitoga mopping the floor in Resident Bedroom #3 during the inspection. The facility was observed to be unclean and unsanitary. Specifically, the loveseat and recliner in the dining area were heavily stained and soiled. In addition, the facility was observed to not be maintained in good repair. LPAs observed that the pantry door did not open easily due to the absence of a floor guide/base slider, making the door difficult to operate. CONTINUED LIC 809-C LPAs observed that resident bedrooms were equipped with the required furnishings and that sufficient lighting was provided throughout the facility. A public telephone was available in the kitchen, and all required postings were displayed. The facility thermostat measured 72 degrees Fahrenheit, which is within the regulatory requirement of 68 to 85 degrees Fahrenheit. LPAs observed that toxic substances were stored in a locked kitchen cabinet and were inaccessible to residents. Sharp knives were also secured in a locked cabinet. Medications were stored in a locked area and were inaccessible to residents. The hot water temperature measured 122.5 degrees Fahrenheit at the resident bathroom sink, exceeding the required regulatory range of 105 to 120 degrees Fahrenheit. Bathroom grab bars were secure and in good repair, and nonskid mats were present in the shower. LPAs observed that the facility maintained at least a seven-day supply of nonperishable food and a two-day supply of perishable food. Smoke detectors and fire extinguishers were in compliance with fire safety requirements. The fire extinguisher was last serviced on 11/17/2025, and the most recent fire drill was conducted on 05/28/2026. The first aid kit was complete. LPAs reviewed and audited medications for four of the six residents by comparing medications on hand with the Medication Administration Records (MARs) and conducting medication counts. During the audit, LPAs determined that the medication count for one of the four residents did not correspond with the resident's medication start date. LPAs reviewed all six resident files and found them to be complete. LPAs also reviewed two staff files. One staff First Aid/CPR certification had expired on 05/31/2026. The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by 07/015/2026 end of day 5:00 PM. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610D Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Administrator Kaloulasulasu 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, Jul 8, 2026

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff locks the front gate

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 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. 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 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 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.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 27-AS-20260102093857

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Mar 13, 2026

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: 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.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: 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. 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).

Type of visit: Post Licensing

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 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.the state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: Case Management - Other

On 8/28/2025 at 3:45 PM Licensing Program Analyst LPA's Shakaricka Hughes and Pang Lee arrived at the facility to conduct a case management visit to deliver an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA met with facility staff Ratu and explained the purpose of today's visit. LPA Hughes handed the Order to Licensee/Facility of Immediate Exclusion from Facility letter to facility staff Ratu and explained that facility staff (S1), if present in the facility needed to leave immediately. Facility staff (S1) is to be removed from all shifts and disassociated from the facility in Guardian. An exit interview was held with Ratu and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Prelicensing

On July 1, 2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct a Pre-Licensing visit following a change of ownership. Upon arrival, LPA was greeted by the applicant, Tevi Kaloulasulasu, who will also serve as the facility administrator. LPA explained the purpose of the visit and proceeded with a brief interview with the applicant Tevi. The census is five. The facility has a fire clearance for 6 non-ambulatory residents only. At this time, the facility is not approved to accept or retain any residents who are bedridden, nor does it have an approved hospice waiver. According to applicant Tevi, the facility will have a live-in staff and will continue to provide 24-hour care, seven days a week. LPA conducted a tour of the facility, inspecting both the interior and exterior, common living spaces, resident bedrooms, bathrooms, the kitchen, and other areas intended for resident use were all toured. It was observed that the furniture and furnishings were adequate and in good condition to meet the needs of the residents at this time. The garage was inspected and observed that the laundry is kept in the garage and LPA observed that laundry detergent, bleach, and other cleaning supplies were safely stored and inaccessible to residents. All required postings were visible throughout the facility. Smoke and carbon monoxide detectors were tested and found to be in good working condition. A fire extinguisher, located in the kitchen and was observed to be serviced and valid until 11/27/2025. LPA toured all five resident bedrooms, as well as one caregiver room. All furniture and furnishings appeared to be in good repair. During the bathroom inspections, hot water temperatures were taken and the hot water temperature measured 116.1 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. Continued LIC 809-C In the kitchen, LPA observed an adequate supply of food at least two days’ worth of perishable and seven days’ worth of non-perishable items sufficient to meet the residents’ needs. Kitchen knives were securely locked and inaccessible to residents. The facility’s internal temperature was observed to be 76 degrees, and a public telephone was available in the kitchen for residents’ use. The linen closet, located in the hallway, contained sufficient supplies of clean towels, blankets, and bed linens. Medications were stored in a locked centralized cabinet located in the front entry closet. Together with the applicant Tevi and caregiver Ratumanoa, the resident’s medications with the medication logs were reviewed, which were found to be complete and accurate. File reviews were conducted for five residents and one staff member, and it was complete. The first aid kit was present and contained the required items. Outside the facility, the physical plant was in good repair, free from hazards. The perimeter fencing was secure, and all gates were in working condition. During today’s visit, LPA Lee observed that the interior layout of the facility does align with the submitted and approved facility sketch. LPA Lee also advised that no changes to the interior or exterior of the facility should be made without prior notification and approval from both the department and the fire department. LPA Lee discussed and recommended the Technical Support Program (TSP) to the applicant, Tevi. The applicant expressed interest in being referred to the program. LPA Lee advised that the referral to TSP will be completed. Based on the observations made during the visit, the applicant has passed the Pre-Licensing component. Component III was also reviewed with the applicant. LPA will notify the Central Application Bureau (CAB) that the Pre-Licensing visit has been completed and passed. An exit interview was conducted, and a copy of the report was provided to the applicant Tevi.the state’s words, verbatim · CDSS document, Jul 1, 2025