Sacramento Senior Living III

Type of visit: Case Management - Deficiencies

On July 28, 2026, at 9:10 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to conduct a case management inspection. LPA Martinez met with Atelaite Peti and explained the purpose of today’s visit. The purpose of the visit today, is in response broken swimming pool fence. LPA Martinez inspected the exterior of the home, the swimming pool, and the swimming pool fence. LPA Martinez observed that the pool is half filled with dirty green mildew water. In addition, the pool had leaf debris, dead grass, and dirt debris in and out and around of the pool. LPA Martinez observed that pool screen gate was not in good. The pool gate latch was broken and the gate screen is caving in due to not being in good repair. In addition, staff one was not able to provide information in regards to how long the pool gate had not been in good repair. The swimming pool gate shall be repaired immediately on July 28, 2026. In addition, until the pool gate is repaired, facility staff shall conduct resident health and safety checks. A health and safety resident check log shall be emailed to LPA Martinez by July 29, 2026 by 5:00 PM. As a result of the case management inspection, the following deficiency was cited per Title 22 Regulations: Personal Accommodations and Services 87307 (e)(2)(a). An immediate health and safety risk civil penalty is hereby assessed for day of July 28, 2026, in the amount of $500.00. The following deficiency can be found on the 809-DPage and LIC 421M. An exit interview was conducted, and a copy of this 809 report, 809 D-Page, and appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(e)(2)(a) · Plan of correction due date: Jul 28, 2026

Personal Accommodations and Services: 87307 (e)(2)(a):The licensee shall supervise residents as needed...Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water...The licensee shall ensure that the bodies of water specified above are inaccessible through fencing This requirement was not met as evidence by: based on observation and interviews, The licensee did not ensure that the large built in swimming pool gate was in good repair. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The facility staff agrees to repair the pool gate by 07/28/2026. Facility staff agrees to email LPA Martinez pictures of the repaired fence by 07/29/2026

Allegation investigated: Staff do not provide resident with comfortable living accommodations Staff do not assist resident with daily living needs Staff mismanage resident medication Staff do not follow resident's special dietary needs Staff open resident's mail Staff did not ensure that resident's continuous glucose monitor was operating Staff did not seek timely medical attention for resident. Staff yelled at residents.

On 07/14/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Ateliate Peti and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6. Allegation: Staff do not provide resident with comfortable living accommodations It was alleged that staff do not provide resident with comfortable living accommodations. This investigation consisted of interviews with facility staff, residents in care, and facility observations. On 07/14/2026, LPA Hughes conducted a visit to the facility and interviewed three (3) residents, who did not express any concerns regarding the facility ability to provide residents with comfortable living accommodations. LPA interviewed staff (S2) who stated that residents are provided with regular housekeeping and laundry services, meals and snacks, and assistance with personal care as needed. LPA observations during the visit were consistent with staff statements, and the facility appeared clean, adequately furnished, and maintained in a comfortable condition. There was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. Continuation 9099-C Unsubstantiated Allegation: Staff do not assist resident with daily living needs It was alleged that staff do not assist resident with daily living needs. This investigation consisted of interviews with residents, facility staff and facility observations. On 07/14/2026, LPA Hughes conducted a visit to the facility and interviewed three (3) residents who did not express any concerns regarding staff assistance with activities for daily living. LPA interviewed staff (S2), who stated that residents receive assistance Activities of Daily Living (ADLs), including bathing, dressing, grooming, meal preparation and medication assistance. LPA observations during the visit did not reveal concerns regarding staff assistance with residents daily living needs. There was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff mismanage resident medication It was alleged that staff mismanage resident medication. This investigation consisted of facility records review. On 07/14/2026 LPA Hughes conducted a visit to the facility, and reviewed Medication Administration Records (MARs) for 4 out of 6 residents in care. LPA did not identify any discrepancies in medication administration for the residents whose records were reviewed. There was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff do not follow resident's special dietary needs It was alleged that staff do not follow resident’s special dietary needs . This investigation consisted of interviews with residents, facility staff and records review. On 03/19/2026 LPA Tamayo conducted a visit to the facility and attempted to interview resident (R1) however, the interview could not be completed. On 07/14/2026 LPA Hughes conducted a follow-up visit and interviewed three (3) residents who did not express any concerns regarding the facility’s compliance with their dietary requirements. LPA interviewed staff (S2), who stated that one (1) resident has a physician ordered special diet and that the facility accommodates resident dietary requirements. LPA reviewed LIC 602 Physician’s Reports for four (4) residents, which identified any prescribed special diets, and there were no evidence that those dietary needs were not being followed. There was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. Continuation 9099-C Allegation: Staff open resident's mail It was alleged that staff open resident’s mail. This investigation consisted of interviews with residents and facility staff. On 03/19/2026 LPA Tamayo conducted a visit to the facility and attempted to interview resident (R1) however, the interview could not be completed. On 07/14/2026 LPA Hughes conducted a follow-up visit and interviewed three (3) residents who did not express any concerns regarding facility staff opening their mail. LPA interviewed staff (S2), who stated that when residents receive mail, the facility provides the items received directly to residents without inspection or opening. There was insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff did not ensure that resident's continuous glucose monitor was operating It was alleged that staff did not ensure that resident’s continuous glucose monitor was operating. This investigation consisted of interviews with residents and facility staff, and records review. On 03/19/2026 LPA Tamayo conducted a visit to the facility and attempted to interview resident (R1) however, the interview could not be completed. On 07/14/2026 LPA Hughes conducted a follow-up visit and interviewed three (3) residents who stated that they do not have any health conditions which require glucose monitoring. Interview with facility staff (S2) did not reveal concerns regarding the monitoring of resident glucose levels. LPA reviewed LIC 602 Physician’s Reports for four (4) residents in care, which did not indicate that any resident required a continuous glucose monitor. There was insufficient evidence to corroborate this allegation. Therefore, this allegation is unsubstantiated. Allegation: Staff did not seek timely medical attention for resident. It was alleged that staff did not seek timely medical attention for a resident. This investigation consisted of interviews with residents and facility staff. This investigation consisted of interviews with residents and facility staff. On 03/19/2026 LPA Tamayo conducted a visit to the facility and attempted to interview resident (R1) however, the interview could not be completed. On 07/14/2026 LPA Hughes conducted a follow-up visit and interviewed three (3) residents who stated that they have no concerns regarding the facility not proving timely medical attention when needed. Interview with facility staff (S2) stated that the facility protocol is to contact the facility administrator to schedule residents medical appointments as needed. Staff further stated that when a resident appears ill or experiences a medical emergency, the facility immediately contacts emergency medical services. There was insufficient evidence to corroborate the allegation. Therefore, the allegation is unsubstantiated. Continuation 9099-C Allegation: Staff yelled at residents. It was alleged that staff yelled at residents. This investigation consisted of interviews with residents and facility staff. On 03/19/2026 LPA Tamayo conducted a visit to the facility and attempted to interview resident (R1) however, the interview could not be completed. On 07/14/2026 LPA Hughes conducted a follow-up visit and interviewed three (3) residents who stated that they have not observed staff yell or speak aggressively to other residents or themselves. Interview with staff (S2) stated that they have never observed any staff speak aggressively or yell at residents in care. There was insufficient evidence to corroborate the allegation. 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 violations occurred. LPA did not observe an activity schedule, activity calendar, or evidence that organized activities were being conducted during the visit. This allegation was observed not in compliance with Title 22 regulation 87219(a) as the facility did not ensure that residents in care were provided with planned activities that support and maintain their quality of life. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 27-AS-20260312171022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(1) · Plan of correction due date: Jul 17, 2026

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include (1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited... This requirement was not met as evidenced by: Based on interviews, and facility observations the facility did not ensure planned activities for residents that support and maintain their quality of life.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: The facility will implement an planned acitvity program that meets the interest and abilities of residents in care. The facility agrees to maintain a written activity schedule and document resident participation. The facility will submit a copy of the activity schedule and a written plan describing how activities will be implemented and maintained to LPA Hughes via email by 07/17/2026 at 5:00 PM.

Allegation investigated: The facility allowed excluded individuals to work in the facility. Staff are forging resident documents.

On 07/14/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Ateliate and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6. Allegation: The facility allowed excluded individuals to work in the facility. It was alleged that the facility allowed excluded individuals to work in the facility. This investigation consisted of interviews with facility staff, residents in care and records review. On 2/19/2026 LPA Tamayo conducted a visit to the facility and spoke with one (1) facility staff who stated they have not seen excluded individuals E1 and E2 present inside of the facility. Interview with six (6) residents in care indicated that they have never seen the excluded individuals inside of the facility. LPA Hughes conducted a follow-up visit to the facility on 07/14/2026 and did not observe the excluded individuals working inside of the facility. Continuation 9099-C Unsubstantiated LPA checked LIC 500 Personnel Report, and Guardian Rosters and did not observe excluded individuals (E1) and (E2) on the reports. There is not enough information or evidence present to corroborate the allegation, therefore the allegation is unsubstantiated. Allegation: Staff are forging resident documents. It was alleged that staff are forging resident documents. This investigation consisted of records review. On 06/26/2026 LPA Hughes conducted a visit to the facility and collected resident LIC 602 Physician’s Reports for 5 residents in care. LPA Hughes reviewed the records and verified that 4 out of 5 LIC 602 Physician’s Reports contained physician signatures. On 07/10/2026, LPA contacted the physician’s offices and confirmed that the signatures on the LIC 602 forms were authentic and consistent with the records maintained by the physicians. There is not enough evidence to corroborate that the facility forged or falsified documents. Therefore, this 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 violations occurred. On 06/26/2026, LPA Hughes conducted a follow-up visit and requested updated LIC 500 Personnel Reports to verify the administrator’s presence. Review of LIC 500 Personnel Reports dated 12/31/2025 through 04/08/2026 reflected a change in facility administrators effective 04/08/2026. During an interview, the facility administrator stated they were unaware they had been designated as the facility administrator until 04/17/2026. However, the records reviewed were not consistent with observations made during the investigation or statements obtained from residents regarding the administrator’s presence at the facility. This was observed not in compliance with Title 22 regulation 87405(a), as the facility did not ensure facility administrator presence in the facility for a sufficient amount of time to effectively manage the facility and carry out duties as required by regulation. Based on the information gathered through this visit, the administrator is not fulfilling administrator duties. A civil penalty of $1000 is being issued today for a repeat violation of Section 87405(a) by not ensuring there is an administrator applicable to conduct administrator duties at the facility. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 27-AS-20260211110157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Jul 15, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by: Based on resident interviews, facility observations, and records review. The facility did not ensure facility administrator presence in the facility for a sufficient amount of time to effectively manage the facility and carry out duties as required by regulation.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: The licensee to submit 40 hour Administrator plan by 07/15/2026 by 5:00 PM.

Allegation investigated: Facility staff did not report communicable disease. Facility staff did not properly monitor residents glucose resulting in hospitalization.

On 06/26/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Atelaite and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6. The facility administrator was not present during today's visit. Allegation: Facility staff did not report communicable disease It was alleged that facility staff did not report communicable disease. This investigation consisted of interviews with residents, facility staff, and records review. On 04/17/2026 LPA Hughes conducted a visit to the facility and interviewed 4 out of 4 residents in care. Interview with 2 out 4 residents stated that they were aware of a resident in care recently being diagnosed with a communicable disease. Interview with resident (R2) stated that they were diagnosed with a communicable disease, received treatment, and was told by the physician the disease was not contagious. Continuation 9099-C Unsubstantiated R2 further stated that the facility took additional precautionary measures and sent the resident for further testing. Interview with the facility staff (S1) stated that the resident was sent out to the hospital and the facility did receive confirmation that the resident communicable disease was not contagious. LPA reviewed resident records, LIC 602 Physician’s report and notes which indicated the resident does not have any signs of active communicable disease and is non-contagious. LPA reviewed the LIC 624 Unusual Incident/ Injury Report sent to CCLD on 04/10/2026 which detailed the resident concerns and facility action. Additionally, LPA reviewed LIC 602 Physician’s Reports for 5 out of 5 residents which indicated negative results for communicable diseases for residents in care. There is not enough information or evidence available to corroborate this allegation. Therefore, the allegation is unsubstantiated. Allegation: Facility staff did not properly monitor residents glucose resulting in hospitalization It was alleged that facility staff did not report communicable disease. This investigation consisted of interviews with residents and facility staff. On 04/17/2026 LPA Hughes conducted a visit to the facility and interviewed Resident (R1), who stated they were last hospitalized in September 2025 due to blood glucose levels and had not been recently hospitalized as a result of facility staff failing to monitor their blood glucose. LPA also interviewed Resident (R2), who stated they do not require assistance from facility staff with blood glucose monitoring, and have not been hospitalized due to blood glucose concerns. Additionally, LPA interviewed facility staff (S2) who stated they were not aware of any recent hospitalization related to inadequate glucose monitoring and reported that (R1) received appropriate care with blood glucose monitoring and care. Based on the information obtained during the investigation, there was insufficient evidence to corroborate this allegation. 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 violations occurred.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 27-AS-20260403101811

Type of visit: Case Management - Deficiencies

On 4/24/2026 at 9:00 AM Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. LPA met with facility staff Peni Vuidreketi. The current census is 4 with 1 facility staff present. The facility administrator was not present during today's visit. The purpose of this visit was to conduct a case management visit regarding deficiencies cited during a previous visit on 4/17/2026. During the visit LPA met with facility staff and reviewed the status of previously cited deficiencies. The LPA conducted a walk through of the facility, made observations, and discussed corrective actions to be implemented by the facility. During the visit LPA spoke over the phone with the facility administrator who stated that the facility has made progress towards correcting the cited deficiencies. It was reported that facility staff have scheduled training to resolve the cited deficiencies on 4/24/2026. LPA did observe medications including sharps disposal containers locked and inaccessible to residents in care. The LPA provided technical assistance regarding regulatory requirements and discussed expectations for maintaining compliance. The facility administrator was reminded that continued monitoring my occur in order to ensure sustained compliance. Per California Code of Regulations, Title 22, the following deficiencies are cited on the LIC 809-D pages, Appeals Rights were provided. Exit Interview was conducted and the facility administrator was contacted to discuss the report a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(C) · Plan of correction due date: Apr 27, 2026

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself...in the facility and the condition or the habits of other persons in the facility... Department to be a safety hazard to others. This requirement was not met as evidenced by: During a facility inspection, LPA observed an open sharps disposal container on the kitchen table. The container was unlocked and accessible in a resident common area, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2026

Plan of correction: Licensee will ensure that the facility remains in compliance with T22 regulation 87465 at all times. Licensee will conduct staff training on proper storage and handling of sharps, and medication related training. Licensee will submit proof of training and a written plan detailing how compliance will be maintained in the faciltiy regarding medication storage and administration of medications. Licensee will submit a plan to LPA by 04/20/2026 and staff training certifications including staff sign-in sheet used will be due on 04/24/2026 via email Shakaricka.hughes@dss.ca.gov

Allegation investigated: Facility administrator is not fulfilling administrator duties

On 04/08/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua was greeted by Staff Member (SM), Peni Vuidreketi and explained the purpose of the visit. LPA Pascua asked SM to contact the Facility Administrator to inform them that CCL was present. LPA Pascua was directed to call, Salote Charlotte Louis however LPA Pascua was unable to reach this individual. LPA Pascua also attempted to contact Facility Administrator but was unable to reach them via telephone. The purpose of this visit was to inform the facility and its representative that a complaint has been filed aginst it at this time. Current Census was 5. A brief interview with SM was conducted. Upon arrival at this facility, LPA Pascua interviewed 3 residents and 2 staff members. It was stated that they do not know who Felipe Naikaso at this time. Further interviews reveal that they are not aware of who the administrator is at this home and have not seen the administrator. In addition, it was stated that Licensee Lewis does not answer their phone. Substantiated During this visit, LPA Pascua attempted to contact Licensee, Salote Charlotte Lewis 4 times via telephone at 12:49pm, 1:00pm, 1:07pm, and 1:15pm. LPA Pascua was unable to leave a voicemail due to the Licensee's voicemail unable to take messages. LPA Pascua also attempted to contact the Facility Administrator, Felipe Naikaso 3 times via telephone at 12:54pm, 1:07pm, and 1:14pm, LPA Pascua was also unable to leave a voicemail at this number. Based on the information gathered through this visit, the administrator is not fulfilling administrator duties. A civil penalty of $1000 is being issued today for a repeat violation of Section 87405(a) by not ensuring there is an administrator applicable to conduct administrator duties at the facility. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An Exit Interview was conducted and a copy of this report was provided to this facility at the end of this visit. There were no signatures obtained for this facility report due to a representative not being available for this visit today.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 27-AS-20260403101811

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Apr 9, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This is not met as evidenced by: Based on interview and record review, the licensee does not ensure that the administrator is present to meet with licensing staff, or adhere to administrator duties as required by the facilities plan of operation. This poses an immediate, health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: The licensee to submit 40 hour Administrator plan by 04/09/2026 by 5:00PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Apr 9, 2026

(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This is not met as evidenced by: The licensee does not ensure that they are available did not ensure that an administrator or quailifed staff were available to meet with Licensing staff. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: The licesee to submit to have a plan in place to ensure that staff are present and available. This plan shall be sent to the LPA by 04/09/2026 by 5:00PM

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Office

An informal meeting was held on 3/27/2026 at 1:00PM, at the Sacramento Regional Office via Microsoft Teams. The purpose of this meeting was to discuss concerns regarding licensed facility Sacramento Senior Living III . Participants in the meeting included: Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA), Cynthia Tamyo, and Licensee/ Administrator Salote Charlotte Lewis. During the meeting, the informal conference process, including the administrative process, was explained to the licensee. The current areas of concern were identified as follows: • Administrator Qualifications • Pre-admission appraisals • Reappraisals • Reporting Requirements • Daily Dietary Needs • Planned Activities • Staff Training • Incidental Medical and Dental-proper storage of medications/insulin • Staff Requirements- sufficient in numbers to meet residents’ needs. • TSP services S1 stated they are Licensee and Administrator for three facilities, Sacramento Senior Living II and Sacramento Senior Living III, and Sacramento Senior Living. Licensee stated the facilities are about 15 minutes away from each other and have looked for a new administrator since last year. Licensee stated that as of 3/25/26, they decided to hire two new qualified Administrators for Sacramento Senior Living II and Sacramento Senior Living III. Continued on 809-C Licensee informed the Department they plan to remain as Administrator for Sacramento Senior Living. Licensee stated the new Administrators will be present at each facility for 40 hours per week, 8:00AM-5:00PM, Monday – Friday and on-call on weekends. Licensee will submit Administrator change request packet. Licensee also stated they have started to conduct weekly audits for Sacramento Senior Living III by visiting the facilities in person. Licensee confirmed TSP was received back in September 2025, which they found helpful but would have preferred if services were provided in person at the Facility. Licensee stated an new initial TSP meeting was held two weeks ago, and a follow up meeting is scheduled for April 9th, 2026. Licensee stated they are going to reach out to TSP to request in-person TSP services instead of having virtual meetings. Licensee stated that they want their new Administrators to be present for all future TSP meetings as well. When asked how they would provide care for R1, who needs a higher level of care, Licensee stated they have a friend who is an Registered Nurse (RN) and they will start to schedule for them to go to the facility “twice per week” to check on the resident’s condition. Licensee also stated they want to ensure their staff are trained to handle emergencies and changes in resident conditions, including reporting any change in condition directly to the Doctor/Physician. Licensee they will be asking their RN friend to also provide training for staff regarding medications including insulin administration in addition to coming into the facility to check on the R1. Licensee stated they want to ensure R1’s disability is accommodated by seeking out resources from the resident’s advocate. Licensee stated they will ensure incident reports sent to the Department are detailed moving forwards; Guidance provided regarding reporting requirements include the need to include dates, times, names, timeline, backgrounds, steps and a follow up report will be provided when necessary. Licensee stated that planned Activities will be discussed with the new Administrator to ensure activities are being provided for residents. Continued on 809-C The facilities will do the following to achieve compliance: • Review regulation for incident reporting • Train facility staff with training regarding Reporting Requirements • Increase Administrator oversight; Hire new Administrator for Sacramento Senior Living III • Review Technical Assistance Program (TSP) resources and request additional assistance when needed. • Disability Accommodation and Personal Rights training for all staff, licensee will retrain facility staff on proper handling, supervision, support, and meeting residents’ needs without infringing on personal rights. The facilities will provide the following documentation to the regional office: • Licensee will submit an updated LIC 500/ LIC 308 for both facilities by 3/30/26. • Submit Administrator change request for new Administrator(s) by 4/3/26. • Staff training in Diabetes, Medication, Special Dietary Meals, and Resident Care and Supervision identifying change in condition, and emergency response for all current staff. • Training in Disability Accommodations and Personal Rights training for residents with disabilities from a disability informed professional. • Ensure Reappraisals are completed every 12 months or whenever there is a change in condition, whichever occurs sooner. The regional office will do the following: • Continue to collaborate and provide assistance to licensee as needed • Offer TSP services A link to a list of approved CEU Vendors from the CDSS website was provided to the licensee to research and find vendor-based training for their facilities:https://www.cdss.ca.gov/inforesources/community-care/administrator-certification/administrator-information/list-of-approved-vendors Per California Code of Regulations (CCR) - Title 22 - no deficiencies are being cited. An exit interview was held, and a copy of the report was sent via email.the state’s words, verbatim · CDSS document, Mar 27, 2026

Type of visit: Required - 1 Year

On 2/19/2026, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at Sacramento Senior Living III for the purpose of conducting a required 1 year annual inspection. LPA met with Staff, Atelaite Peti (S3). Upon arrival, the Administrator (S1) was not present at the facility, S3 contacted S1 to inform them of the purpose of today's visit. An entrance interview was conducted. Sacramento Senior Living III is a residential care elderly (RCFE) licensed to serve 6 adults age range 60 and over. Approved for 6 non-ambulatory. Waiver/granted for hospice care for (2). LPA observed there to be one staff and and five residents in care, of which none are in hospice. LPA toured the facility with S3 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 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. S1 will ensure the thermostat is operating at all times and the temperature is set to a comfortable temperature for residents within regulation limits. The facility's water temperature measured 104 degrees Fahrenheit in restroom #1 and measured 104.7 degrees Fahrenheit in restroom #2, which is not within the required range of 105 and 120 degrees. LPA Tamayo observed first aid supplies, a fully- charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Tamayo observed a minimum 2- day supply of perishable food and a minimum 7-day supply of nonperishable food. Continued on 809-C LPA observed a locked cabinet for the storage of medication. LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives. Medicine lock box in the refrigerator was locked and inaccessible to residents in care. LPA also observed some electrical outlets thought the home were loose and there is a toilet paper/towel holder in disrepair in bathroom #2. LPA observed the trash bins were emptied out. S3 stated the trash is taken out everyday 1-2 times per day. The exterior of the building was inspected by the LPA. LPA observed a pool in the back yard that is fully enclosed by fencing that meets regulations and is inaccessible to residents without supervision, the yard was completely fenced in. LPA observed broken glass piled on the ground, S3 did not know where it was from nor the plan for disposal. Facility will ensure to have someone remove the pile of shards by end of day. There was also a sitting area for residents in the backyard. LPA observed there is one chair that is in need of repair or disposal. LPA observed lunch was provided for 4 of 5 residents, it was a turkey sandwich. 1 out 1 resident did not have lunch due to there not being a vegetarian or diabetic appropriate option. LPA observed S3 prepare chicken which will be used for dinner and an alternative option with vegetables and tofu will be offered. At around 3:00PM LPA observed groceries were delivered. LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. The posted LIC 500 did not list S3. LPA provided guidance on ensuring LIC 500 is updated each time there is a staffing change. LPA reviewed 3 staff records and 5 resident records. Administrator certificate # 7027423740 and it expires 8/8/26. LPA provided guidance regarding Administrator oversight. LPA requested the following documents: LIC 500: Personnel Report , received LIC 308: Designation of Administrative Responsibility, received LIC 402: Surety Bond, if applicable LIC 610E: Emergency Disaster Plan, received LIC 309: (for any LLC or Corp) if applicable Copy of Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S3 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, Feb 19, 2026

The state marks this report as 19 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management visit on incident reports received. LPA met with Josaia Sigavata (S2) and explained the purpose of the visit. Licensee (S1), Salote (Charlotte) Lewis, was not present during this visit. S2 stated that S1 was present at the facility this morning. LPA called S1 and left a voice message requesting a call back. The purpose of this visit is to follow up on an incident report and death report received for Resident 4 (R4). The incident received for R4 was dated 12/16/2025 regarding a resident being sent out to the hospital due to R4‘complaining of abdominal pain’. A Death report for R4 is dated 12/16/25 states that R4 died at the hospital on 12/15/25 due to “multiple underlying conditions”. S2 stated they do not know if the death certificate has been requested. Per records review, R4 was admitted to this facility on 6/3/2025. During a case management visit in November 2025, it was discovered that R4 had was transported to the emergency room on 11/4/25 due to a sustained rib fracture the day prior while out with their family, the facility did not submit a timely incident report. On 11/20/25, a deficiency was cited for 87211 Reporting Requirements (a)(1) which consisted of Licensee will submit incident report for R4 to licensing and responsible party along with a statement agreeing to review 87211(a)(1) and report all special/unusual incidents to licensing and responsible parties in a timely manner by 12/4/25. Incident report (SIR) dated 11/4/25 for R4 was not submitted to LPA as stated on POC due date 12/4/25; LPA observed SIR dated 11/4/25 was available for review at the facility (SIR binder). Contunued on 809-C Licensee will submit an additional SIR regarding the incident, as the one on file does not inform of the diagnosis of fractured ribs and discharge details. LPA observed R4’s reappraisal dated 11/4/25 was not in R4’s physical record/binder maintained at the facility. The re-appraisal was submitted to LPA via email. LPA observed all medical visit verifications including discharge paperwork, after care summaries for R4 were not available for review at the facility during this visit. LPA reviewed POC requirements and record keeping requirements with S2. As of 12/23/25, CCLD has not received a request to change administration designation to S1; the current assigned administrator is S2, whom is no longer working at the facility and is now disassociated. S1 stated they will submit a request to designate themselves as administrator. A civil penalty for repeat violation applies. On 12/22/25, LPA spoke with S1 via phone call to follow up on administrator status, S1 stated they are still in the process of hiring a new administrator and they are acting as administrator for this facility. At around 2:30PM on 12/23/25, S1 informed LPA they are not able to come to the facility during this visit due to being in Rocklin for “networking for administrator… Ill be there again this evening”. At around 4:08 LPA Tamayo and S1 set up a phone call for 12/24/25 at 9:30AM. At 3:40PM during this visit, LPA Tamayo observed a new resident arrived and was moving into the facility during this visit. S2 stated admission packet is set to be completed with the new resident this evening. LPA is requesting the following facility documents to be submitted by 12/24/25: November and December LIC 500s, LIC 9020, visitor sign in/out sheet (September - December) Additionally, the following records for R4 if they have not yet been submitted to LPA Tamayo on 12/23/25: All appraisals, admission agreement, LIC 601, LIC 602, incontinence logs, daily notes, Home health contact information, home health care plan and notes, verification of all incident reports, all doctor visit appointments, after care summary, all discharge paperwork, death certificate. As a result of this case management , there are two Title 22 Regulation deficiencies cited. Deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the S2.the state’s words, verbatim · CDSS document, Dec 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 24, 2025

87465 Incidental Medical and Dental Care (h) ... to medications which are centrally stored: (2)... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication ... this requirement was not met as evidence by the facility continuing to not ensure medications/insulin is stored properly and with a locking mechanisms and is locked/inaccessible to residents, this poses a potential/immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: By POC due date, licensee will ensure all medications are stored properly and with a locking mechanisms locked/inaccessible to residents who are not able to self administer medications along with a plan to train staff on 87465. This repeat vioaltion constitutes a civil penalty.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Dec 24, 2025

87405 Administrator - Qualifications and Duties(a) ... qualified ... administrator shall have sufficient freedom from other responsibilities... on the premises a sufficient number of hours ... a designated substitute ... qualifications adequate ... this requirement was not met as evidenced by licensee not updating the assigned facility administrator with community care licensing by previous POC due date 12/3/25, this poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: By POC due date, Licensee will submit a request to update administrator to community care licensing. Licensee will also submit a statement of understanding of 87405(a) and requirement to designate an administrator and administrator substitute(s) who shall have adequate qualifications. This is a repeat violation and a civil penalty applies.

Type of visit: Case Management - Deficiencies

On 11/20/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a case management -deficiency visit for deficiencies observed on 10/20/25 and 11/7/2025. LPA met with care staff Josaia Sigavata (S1) and explained the purpose of the visit. S1 called Licensee, Salote Lewis, to inform the LPA was at the facility. Licensee told S1 to assist LPA with this visit. Based on interviews with S1, R3, and R4 stated R4 it was reported that R4 had an ER visit due to sustaining a rib fracture when they were with their family member in which S1 called the ambulance when R4 was complaining of pain on the night of 11/4/25. Discharge paperwork for R4 dated 11/5/25 state R4 obtained a rib fracture (when out with their family on 11/4/25) an incident report was not sent to Licensing. S1 stated Licensee was informed resident was transported via ambulance. At 3:00 PM 11/7/25, S1 stated Licensee was made aware S1 called 911 for R4 due to their rib pain. At around 2:10 PM, LPA spoke with Licensee over the phone on 11/7/25 and they stated there was no recent incidents to report. As of, 11/19/2025 Facility did not meet timely reporting requirements. Additionally, Record review does not show there was an updated appraisal/care plan for facility staff created for R4 after they were discharged with a fractured rib, which constitutes a change of condition. Moreover, LPA observed there was a Tylenol bottle that was over half way full next to R4s bed. Tylenol is listed as a PRN for R4, and should locked and inaccessible to resident in a centrally stored location, this deficiency was cited on a separate LIC 9099 dated 11/19/25. On 10/30 and 11/7/25 LPA Tamayo observed the kitchen refrigerator stored a lock box insulin needles for one resident was closed but it opened freely because the it was not locked with a key, S1 and R2 stated they did not know where the key is. Although R1 is able to self administer medications with some assistance, LPA Tamayo observed insulin needles are stored in the mini-refrigerator of R1’s bedroom without any locking mechanism. CONTINUED ON 809-C At around 1:00PM on 11/7/2025, a maintenance person arrived to repair a hole on the side of the homes exterior leading into the garage as well as the hallway toilet. The maintenance worker told S1 they will remove the toilet and make the repairs by end of day. Resident 1 R1 stated they went to use the bathroom and almost fell into the hole where the toilet was previously placed, "no one told me …. there was no toilet … I could have seriously hurt myself ... I'm blind". S1 stated they did not tell R1 the toilet was removed, because R1 was on the phone. LPA spoke with staff regarding providing accommodations including informing residents with visual impairments if furniture items are moved, ensuring there are no obstructions, or hazards as stated on the needs and services plan. The facility did not ensure accommodation for all residents are being done. LIC 602 for R1 states the resident needs direction with moving around the facility, “ensure environment is clutter free and easy to maneuver … free of tripping hazards … [staff will] provide orientation and mobility training as needed”, however, LPA has not observed staff assist R1 with direction around the facility on 7/28/25, 9/10/25, 10/30/25, 11/7/25, or 11/19/25. During LPA’s visit 11/7/25, LPA observed the right side basin of the kitchen sink was filled with water and had a sealed packet of meat floating inside the sink. Witness 1 (W1) stated they have seen meat thawing on the kitchen sink on more than one occasion. Staff stated they would get a separate basin to thaw meats. LPA conducted record review of staff records for S1, S2, S4, and S5 and there was no staff file for S5, incomplete documents for S4, including LIC 501 , and there were incomplete training verifications available for review for S1, S2, S4, and S5. On 11/19/25, LPA observed S1 was using a separate designated basin to thaw a steak that was going to be prepared for dinner. Additionally, It was reported that Staff 1 (S1) had their family over on the evening of 11/6/2025 for dinner time. Staff is not able to host personal gatherings especially with individuals who do not have criminal background and TB clearance prior to entering the care home. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation. An exit interview was conducted with the Licensee, and a copy of these LIC 809, 809-D reports and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 4, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency (1) A written report ... submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)... this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: By POC due date Licensee will submit incident report for R4 to licensing and responsible party along with a statement agreeing to review 87211(a)(1) and report all special/unusual incidents to licensing and responsible parties in a timely manner

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Dec 4, 2025

87463 Reappraisals (a) ... as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary ... to note significant changes in conditon...referred to as the reappraisal. This requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: By POC due date, licensee agrees to review 87463(a) and complete a reappraisal for any resident that has not had one in the last 12 months or if there has been a change in condition since the last reappraisal.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 21, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipmentthis requirement was not met as evidence by: Care staff did not accord residents, including residents with blindness, timely notification that the toilet was removed for maintenance on 11/7/25 resulting in an incident in which R1 going to use the bathroom as usual without knowing the toilet had been removed. Additionally, the two resident interviews in which it was learned that care staff using work hours for personal social gathering on 11/6/25, this shows failure to perform required duties and introduced uncleared individuals to the environment. This poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: By POC due date, Licensee will submit a statement of review and understanding of 87468.1 along with a plan ensure only authorized individuals are allowed in the care home and a plan to accord accommodations for residents whom need assistance with navigating the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(2) · Plan of correction due date: Dec 4, 2025

87465 Incidental Medical and Dental Care (h) ... to medications which are centrally stored: (2)... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication ... this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: By POC due date, licensee will ensure all medications are stored properly and with a locking mechanisms locked/inaccessible to residents who are not able to self administer medications along with a plan to train staff on 87465.

Allegation investigated: Staff did not ensure the facility is free of rodents and insects. Staff did not ensure safe assistance with glucose testing is available to diabetic residents. Staff did not ensure modified diets as prescribed by a resident's physician are provided to residents. Staff did not ensure timely administration of medications. Staff does not have sufficient training on preparing diabetic-appropiate meals for residents with diabetes. Staff did not ensure there are an adequate number of staff to meet residents needs. Staff did not ensure there is awake staff 24/7. Staff did not ensure there is a working alert device feature on exterior doors at all times. Staff does not provide activities for residents. Administrator does not spend sufficient number of hours at the facility. Administrator does not assist to meet health care needs for resident for annual doctors visits.

At 3:44 PM, on 11/19/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a complaint visit. The purpose of this visit is to complete and deliver complaint findings for the allegations aboveLPA met with care staff Josaia Sigavata and explained the purpose of the visit. A brief interview conducted with care staff, Josaia Sigavata. The current census is five residents with one staff. It was alleged that staff did not ensure the facility is free of rodents and insects. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. During multiple unannounced visits conducted on 10/30/25, 11/7/25 and 11/19/25, LPA observed there were flies in the kitchen area. On 11/7/25, at around 2:00 PM, LPA observed the kitchen trash bins, hallway bathroom trash bins, trash bins in two residents’ bedrooms were full and in need of disposal. CONTINUED ON 9099-D Substantiated LPA talked to staff regarding the importance of taking out the trash more than once a day, as needed to keep the facility clean, order free, and free of rodents and insects. On 10/30/25, LPA observed there was a cat in the facility, two residents reported the cat was brought in due to the "mouse problem". On 10/30/25, LPA observed there was a hole on the exterior wall on the right side of the home of the home which leads into to the garage. Licensee stated they would repair the hole. On 11/7/25, LPA observed a maintenance worker was working on covering up the hole on the side of the house. Two residents stated there are cockroaches and flies in the home. On 11/7/25, Licensee stated they would look into placing screen doors and a secure cat door to prevent rodents and insects from entering the home. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation staff did not ensure the facility is free of rodents and insects. It was alleged staff did not ensure safe assistance with glucose testing is available to diabetic residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. During an unannounced visit conducted on 11/7/25 at around 2:18PM, R1 stated they have not had any breakfast and have been waiting for their medication and breakfast since the morning. S1 reminded staff they needed to have their medication before having their meal. LPA observed S1 obtain an insulin pen injector from R1’s mini fridge, which was accessible without any locking mechanism. LPA observed S1 did not have any alcohol prep pads nor were they wearing any gloves when handling resident medications. On 9/10/25, LPA discussed the need to providing staff training for staff caring for with diabetes and an updated plan to address the care needs for residents with social diets and blood sugar checks, of which a plan of correction was submitted 10/8/25. Additionally, during multiple visits including 10/30/25, 11/7/25, and 11/19/25, LPA observed medications assistance were administered at different times each day.Witness 2 (W2) stated R1 attended a medntal health appointment at 10:00AM without eating anything prior, which resulted in the CGM constantly beeping due to low blood sugar readings. R1 stated they requested staff to knock their door and wake them up in the morning to ensure they do not miss medication administration or meals in the mornings to ensure their glucose level is not disregulated. on 8/29/25, R1 was hospitalized due to having keto acidosis. On 11/7/25, R1 did not have any breakfast until 2:28PM. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation. It was alleged that staff did not ensure modified diets as prescribed by a resident's physician are provided to residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. CONTINUED ON 9099-D. Record review revealed that the appraisal for R1 dated 5/ states they are on a restricted carb diet, and is vegetarian, the LIC 602 form in which their needs and services care plan states that staff will accommodate alternatives are not available for residents who Vegetarian or have diabetes. The appraisal/needs and services plan for R1, dated 5/8/25 states the staff will provide “diabetic vegetarian meals” and daily insulin checks. During an unannounced visit conducted on 11/7/25 at around 2:18PM, R1 and witness 1 (W1) stated they had not had any breakfast and needed to eat hours ago. S1 stated R1’s meal was ready and, in the microwave, until they were ready to eat. R1 stated they have been ready to eat since the morning and reminded staff they needed to have their medication before having their meal. S1 stated R1 did not ask for breakfast and they only had coffee. After medication was provided to R1, LPA observed R1’s meal was served at around 2:28PM which consisted of a bowl of scrambled eggs with cheese. S1 stated one resident had pancakes for breakfast and another had eggs that same morning. LPA observed R3 has sausage sandwich for lunch at around 2:00 PM. On 11/7/25, S1 showed LPA there was a special diet menu posted on the inside of the kitchen cabinet of which the menu did not show what was to be served on Fridays not does the menu provide alternatives for residents with special diets whom does not eat any meats. There are three residents with diabetes and two residents that do not eat meat(s) and/or pork. The posted menu from the plan of correction dated 10/8/25, lists breakfast to be French toast, bacon, orange slices, and milk and the lunch option lists: tuna salad sandwich with vegetable soup. LPA observed inventory of the kitchen foods does not obtain all foods listed on the posted menus. R1 buys their own food because the facility is not accommodating their dietary needs and preferences. W1 stated “what they provided , given hashbrown and toast for breakfast. Blood sugar levels are all over the place … Caregiver asks Cody what to cook instead of knowing what they can have”. On 11/19/25, At 4:50PM LPA observed S1 begin to prepare dinner. S1 stated dinner would be steak, mashed potato, and watermelon for dinner of which Tofu would be offered as a meat alternative. Moreover, LPA observed there is a separate menu posted in the hallway bulletin board that is titled, “Weekly Menu For Sacramento Senior Living Residents (Diabetes And Hypertension)”, of which breakfast should have been Greek yogurt, strawberries, and a muffin and lunch is chickpea curry, rice, and salad. LPA did not observe any of these options to be offered or available to residents with diabetes. CONTINUED ON 9099-D Witness 2 (W2) stated R1 attended a medntal health appointment at 10:00AM without eating anything prior, which resulted in the CGM constantly beeping due to low blood sugar readings. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation. It was alleged that staff did not ensure timely administration of medications. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. LPA conducted record review of 5 out of 5 resident records, R1’s LIC 602, reveal R1 they are able to administer medication but needs assistance with ensuring it is the correct dosage and may need help denying medications due to being blind. S1 residents stated there is only one care staff during each shift to care for five residents and medications have not been given at the same time each day because residents are sometimes asleep and do not wake up. Staff will put a plan is in place to ensure medications are administered around the same time frame each day for each resident moving forward. Based on observation, records review and interviews statement conducted during the investigation process Tamayo Lee was able to corroborate the allegation. It was alleged that staff does not have sufficient training on preparing diabetic-appropriate meals for residents with diabetes. LPA interviews with two residents, one staff, and LPA observations from 10/30/25 and 11/7/25, staff does not have sufficient training on preparing diabetic-appropriate meals to meet the needs of three diabetic residents residing in the home. LPA’s resident record review reveals that the appraisal/needs and services plan for R1, dated 5/8/25 states the staff will provide “diabetic vegetarian meals”. On 9/2/25, Licensee submitted an unusual incident report that reported R1 was sent to Emergency Department on 8/27/25, as R1 was “staff observed resident vomiting. Due to his diabetic condition incident was immediately treated as urgent”. Discharge records reveal R1 had Keto acidosis. The plan of correction dated 9/10/25, agreed to provide staff training for staff caring for with diabetes and an updated plan of care including a monthly menu to be implemented to address the care needs for residents with social diets and blood sugar checks to be implemented by 10/8/25. LPA has only observed eggs, oatmeal, rice, and sandwiches to be served for breakfast and lunch on past visits. LPA has not observed there to be alternatives offered to residents before or during meal times. Based on observation, records review and interviews statement conducted during the investigation process LPA Tamayo was able to corroborate the allegation, in which a $250 civil penalty for repeat violation applies. It was alleged that staff did not ensure there are an adequate number of staff to meet residents needs. CONTINUED ON 9099-D The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. Two residents stated there is only one care staff during the day and they clean, cook, change residents, bathe residents. Three residents stated the licensee is only there a “few hours” per week. Two residents stated that most needs are being met but the quality of care is not there, and it is too much work for one care staff to do. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation. It was alleged that staff did not ensure there is awake staff 24/7. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party. On 9/11/25, facility submitted a plan of correction in which they agreed to have overnight staff due to elopement of one resident with a diagnosis of dementia. . Licensee stated there is one wake staff, staff 3 (S3), but residents don’t see them because they are in their rooms, S3 is scheduled from 10:00PM- 6:00AM every day. Per LIC 500, S4 is scheduled on weekends between 7AM-7AM, Licensee confirmed was no night staff on 11/6/25, but they were there days prior. License stated there was no back up wake staff for the designated night staff is not working such as on 11/6/25. S1 stated there has not been night staff for a “couple of weeks”. Four residents stated they have not seen any night staff aside from S1 who sleeps in the staff room, usually after 10:00PM. On the night of 11/4/25 , residents alerted S1 that R4 needed to go to the hospital and S1 called 911. S1 stated it was after 10:00PM and they were the only staff present. Based on observation, records review and interviews statement conducted during the investigation process, LPA Tamayo was able to corroborate the allegation. It was alleged that staff did not ensure there is a working alert device feature on exterior doors at all times. The investigation included observations, record review, and interviews with facility staff, residents in care and residents’ responsible party. On 10/30/25, the facility was cited for not ensuring there is a working alert device feature on doors at all times via a case management visit. There is a recent plan of correction stating that licensee will put a plan in place to installing a hard-wired alarm system on exit doors. LPA confirmed a hardwired alarm system has been installed as of 11/10/25. Device to be installed within two weeks of citation issuance. On 10/31/25, W1 stated that the alarm system was off. Based on observation and interviews statement conducted during the investigation process, the allegation is substantiated. A new citation will not be applied due to the facility being cited on 10/30/25 in which the plan of correction has now been completed. CONTINUED ON 9099-D It was alleged that the staff does not provide activities for residents. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party. Record review reveal the appraisal/needs and services plan for R1 sta-R3 state that staff will to facilitate participation in social activities and daily access to activities. On 11/7/25, LPA observed the posted activity calendar on the bulletin board is for activates offered in July and August. Three residents stated the majority of the activists listed on the activities calendar were offered not to residents except for an attempt to have a BBQ on the fourth of July and some movie nights. On 9/10/25, 10/30/25, and 11/7/25, LPA has not observed any activities being offered to residents aside from residents watching television in their bedroom and/or in the living room. Based on observation, records review and interviews statement conducted during the investigation process LPA was able to corroborate the allegation. It was alleged that the Administrator does not spend sufficient number of hours at the facility. The investigation included observations, record review, and interviews with facility staff, residents in care and residents responsible party, and outside agencies. Sacramento Senior Living III was licensed April 2025, in which Tevita Kaloulasulasu (A1) is the designated Administrator. On 11/7/25, LPA observed the posted LIC 308 lists A1 as the Designated Facility Responsible person. On 11/7/25, two staff and two residents stated A1 has not been working at the facility for over a month. LPA was not aware that Former Administrator Kaloulasulasu had stopped performing administrator duties and responsibilities and is no longer working at this facility. One outside witness also confirmed that they have not met or communicated with an Administrator at the facility and have only interacted with care giving staff. Licensee, Licensee (Charlotte) Lewis (L1) stated they are filling in as the administrator in the meantime in addition to being an administrator at two other facilities. LPA observed the updated LIC 308 listing care staff, S1, as the Designated Facility Responsible person was not yet updated on the facilities records included the posted LIC 308 dated 8/2025. During unannounced visits conducted on 10/30/25 and 11/7 did not observe an Administrator or licensee present at the facility. LPA advised staff to review Title 22 requirements to have a qualified administrator to cover for the administrator when the administrator is not available. License shall update the administrator and facility designated responsible person, since A1 is no longer working at the facility. CONTINUED ON 809-D Per LIC 308, licensee agreed to notify licensing in writing within ten days of any change in the LIC 308 authorizations, the facility did not notify licensing of this change timely. Based on observation, records review and interviews statement conducted during the investigation process, LPA was able to corroborate the allegation. It was alleged that the Administrator does not assist to meet health care needs for residents for annual doctors’ visits. The investigation included observations, record review, and interviews with facility staff, residents in care, residents responsible party, and outside agencies. Three residents stated they have not had any dentist appointments in the last year. Two witnesses, W1 and W2 stated one resident has missed medical appointments due to not having transportation as a result of the facility not having enough staffing or administrator oversight. Licensee stated they have not arranged any dental appointments for residents who have not had the required dental visits prior to becoming licensed in April 2025, but will make arrangements for all residents to have the required annual medical appointments this month. Based on observation, records review and interviews statement conducted during the investigation process LPA was able to corroborate the allegation. As a result, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff, S1, and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 27-AS-20251104081616

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(b)(4) · Plan of correction due date: Nov 20, 2025

87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by interviews that reveal diabetic resident, R1, has missed meals and is not being offered meals that are appropriate for their diabetic and dietary needs. On 11/7/25, R1 did not have breakfast nor medication until 2:28PM. On 8/27/25, R1 was hospitalized after a keto acidosis episode. The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for special diet needed for residents with diabetes.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: By POC due date, the facility will submit a plan to ensure there are diabetic appropriate meals for residents in care who have a diagnosis of diabetes meals as well as ensure trained staff to provide timely and safe assistance with medication administration.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f) · Plan of correction due date: Dec 3, 2025

87303 Maintenance and Operation (f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents... This was not met as evidence by: Based on interviews with staff and residents confirming there is a mouse infestation. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: By POC due date, licensee will submit a plan to ensure the facility is free of pests, rodents, and insects including a scheduling an exterminator to start to treat for pests, rodents, and insects before 12/19/25. Licensee will also provide staff with a cleaning schedule and training including the requirement to take out the trash in all rooms twice a day or more if needed and doors are closed in order to prevent rodents or insects from entering the home.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: Nov 26, 2025

87628 Diabetes (a) ... resident who has diabetes ... able to perform his/her own glucose testing .... able to administer his/her own medication .... or has it administered by an appropriately skilled professional. This was not met as evidence by: Based on interviews and observation, in which it was observed that Staff 1 (S1) did not ensure to safe administration of insulin was done by not using gloves nor use sterilizing pad when assisting resident 1 (R1) with their medications and that timely administration of medications is taking place. This posed an immediate or potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: by POC due date, the facility agrees to ensure residents who have diabetes are able to administer his/her own medication safely or has it administered by an appropriately skilled in a timely manner.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d) · Plan of correction due date: Dec 3, 2025

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. This was not met as evidence by: Based on interviews and observations, it was learned staff is still not adequately trained on providing modified diets as prescribed by a resident's physician, dietary restrictions, and resident preferences are provided to residents.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: By POC due date, licensee will ensure there is an updated training on ensure modified diets as prescribed by a resident's physician are provided to residents and an updated meal is created along with staff and residents

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 3, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met as evidenced by interview and observations in which it was learned one care staff is not enough to meet the needs of five residents in care. Additionally, there should be wake staff at night time due to the facility having an exit seeking resident with a diagnosis of dementia; this poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: by POC due date, licensee will submit plan to ensure there is at least two care staff to ensure needs of five residents in care including ensuring there is enough staffing to ensure transportation to and from medical appointments for residents are accounted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 7219(a)(1) · Plan of correction due date: Dec 3, 2025

7219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:(1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to... This requirement was not met as evidenced by interview observations and interviews in which it was leaned no activities are being offered to residents in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: by POC due date, facility will create an activity calendar and staff tracings to plan, coordinate, and follow through of the provision of enrichment activities for as outlined in the plan of operation, admission agreements, appraisal for residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Dec 3, 2025

87405 Administrator - Qualifications and Duties(a) ... qualified ... administrator shall have sufficient freedom from other responsibilities... on the premises a sufficient number of hours... attention to the management and administration ... a designated substitute ... qualifications adequate to be responsible and accountable for management and administration When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: By POC due date, Licensee will submit a request to update administrator, updated LIC 308, and updated LIC 500 by POC due date. Licensee ages to designate an administrator and administrator institute who shall have qualifications adequate to be responsible e and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 3, 2025

87465 Incidental Medical and Dental Care (a ) A plan for incidental medical and dental care ... routine medical and dental care and provide for assistance in obtaining such care.. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents This requirement was not met as evidence by record review and interviews in which it was learned that 4 out of 5 residents not having dental care verification in over a year as well as routine medical doctors visit. Additionally, resident 1 (R1) has missed medical appointments due to not having assistance with transportation arranged. this poses a potential health an safety risk for residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: By POC due date,licnesee will submit plan to ensure all residents have assistance with scheduling and attending routine medical visits as required for each resident.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Tamayo arrived at this facility unannounced on 10/29/2025 to conduct a case management visit. LPA met with care staff Josaia Sigavata and explained the purpose of the visit. LPA called Licensee, Salote (Charlotte) Lewis over the phone. The current census was five, as one resident was out with their family. There was one facility staff, S4. The purpose of this visit is to follow up on deficiencies learned during review of incident report in which a resident eloped from the facility on 10/21/25. The incident report and interviews reveal the resident is turning off the alarms, Licensee will put a plan in place to fix it, such as installing a hard- wired alarm system. A Civil Penalty (CP) for absence of supervision was issued on 9/10/2025. LPA provided guidance to staff regarding care and supervision and have been reminded that the facility alarm system shall not substitute for care and supervision. A $500 CP for residents' elopement on this visit. The deficiency cited from the California Code of Regulations, Title 22, and California Health and Safety Code can be found on the 809-D page. An exit interview was conducted with care staff Peti and a copy of the 809 report, 809-D page, 9102s and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Oct 31, 2025

87705 Care of Persons with Dementia (d) ... shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents ... risk for elopement ... This requirement was not met as evidenced by: Based on observation and interview, Licensee did not ensure adequate alert and monitoring devices on all exterior doors and gates despite knowledge of elopement risk for R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Licensee will put a plan in place to fix it, such as installing a hard-wired alarm system. Licensee to submit proof of purchase and plan for installation of alert and monitoring device to LPA by POC due date. Device to be installed within two weeks of citation issuance. Elopement prevention plan to continue before and after device installation.

Type of visit: Case Management - Deficiencies

On 9/10/25 at 9:02 AM Licensing Program Analyst (LPA) Cynthia Tamayo conducted an unannounced case management inspection to address previous incident reports and deficiencies in facility operation. LPAs met with administrator, Tevita Kaloulasulasu (S1) and together discussed incident reports from 8/29/25. LPAs conducted file review and observed LIC 603A physician's report is dated 12/21/2023 and Resident 1 (R1) is need of an updated version. S1 stated R1 has an appointment with physician to get an updated physicians report on 11/11/25. Based on LPA observations, interviews, and resident file review, LPA has determined, based on resident needs, there must be awake night staff available at the facility to meet resident needs during overnight hours. S1 stated they are asleep overnight. Staff performing overnight duties must be awake during all hours of the overnight shift. The department has determined the facility did not meet resident needs for care and supervision per the current Personnel report (LIC 500) and residents with diagnosis with dementia. This was documented by an incident report dated 8/29/25 where R1 eloped from the facility and the resident's physician report indicated that resident is unable to leave the facility unassisted. The department received an incident report from 8/27/25 regarding Resident 3 (R3). Staff will obtain updated physicians report and complete a re-appraisal this month. Staff stated R3 and R4 are able to perform their own glucose testing with blood specimens, and is able to administer own medication including medication administered orally or through injection. Continued on 809-C S1 stated they are seeking to obtain home health nurse assistance for R3 to have an appropriately skilled professional start to assist R3 with checking their blood sugar due to R3 being blind and need for a re-assessment. Based on LPA observations, interviews, and resident file review, LPA has determined, special diet is not being followed for residents with diabetes. Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. An Immediate $500 civil penalty was issued during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 11, 2025

87411Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs ... shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds... licensing ... may require... to provide additional staff... This requirement was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: The administrator/licensee has agreed review regulation 87411(a) and provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87628(b)(4) · Plan of correction due date: Oct 8, 2025

87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by: The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for special diet needed for residents with diabetes.the state’s words, verbatim · CDSS document, Sep 10, 2025

Plan of correction: The administrator/licensee will conduct staff training for persons caring for with diabetes and updated plan of care including a monthly menu will be implemented to address the care needs, specifically for social diets and blood sugar checks for residents with diabetes.

Type of visit: Post Licensing

On 7/28/2025 at 1:09 AM, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at the facility for an announced to conduct a Post-licensing inspection. LPA was greeted by staff member, Josaia Sigavata and explained the purpose of the visit. Facility Designated Administrator (FDA), Solate (Charlotte) Lewis was contacted by staff. LPA Cynthia Tamayo met with staff Josaia Sigavata and explained the purpose of the visit. Staff member Josaia Sigavata is associated to the facility and has a currect CPR certification. Tevita Kaloulasulasu holds an active administrator certificate # 6072342740and is valid until 10/24/2026. Current census was 5. This facility a Residential Care Home for the Elderly (RCFE) licensed to serve age range 60 and over, approved for 6 non-ambulatory. The facility has a waiver granted for hospice care for two (2). There is one staff bedroom that is inaccessible to residents. There are currently no residents on hospice at this time. LPA reviewed 5 out of 5 resident files and 3 staff files. Resident and staff files were complete. Hot water temperatures were taken to ensure it was in the regulation of 105-120 degrees and it measured at111.7 * F. Carbon monoxide and smoke alarms were present and were in working condition. A sample menu was observed in the kitchen area. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. The facility temperature was at 71 degrees Fahrenheit which is within the required range of 68-85 Fahrenheit. Continued on 809-C Grab bars and non-skid mats were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. LPA observed an operating telephone (916-509-9693) located in the living room. A linen closet was located in the hallway and had sufficient number of linens at this time. The kitchen area was toured. Facility freezer and refrigerator showed to be functional. LPA Tamayo observed that there were not 7 days of nonperishable food in the pantry. LPA Tamayo observed the centrally stored medications area to be locked and inaccessible to residents. The fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) were in good repair. An activity Calendar was observed in the common areas. The pool is gated and inaccessible to residents. The facility has a cleaning maintenance scheduled for the pool. The following documents will be email to LPA by 8/4/25 end of day 5:00 PM: 1) LIC 308 current Designation of Administrative Responsibility 2) LIC 9020 current Resident Roster 3) Daily/weekly menu with special diet modification for each resident for July- August 2025 4) Activity Calendar for July – August 2025 5) Dementia Training verifications for all staff 6)LIC 500 Personnel Report for July - August 2025 As a result of this post licensing visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Josaia Sigavata and a copy of these LIC 809 reports were provided to the facility.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Prelicensing

On 4/25/2025 Licensing Program Analysts (LPAs) Cynthia Tamayo and Kevin Gould arrived at Sacramento Senior Living III for the purpose of conducting a change of facility ownership pre-licensing continuation inspection. LPAs met with Licensee, Salote Lewis, and Administrator, Tevita Kaloulasulasue, and together conducted a tour of the home. There are currently four resident in care. At the time of inspection, the facility has met all pending requirements to be licensed at this time. The following corrections have been completed: Pool fence is able to be locked. all bedroom and bathroom drawers and cabinets are in working order LPA reviewed Component 3 with the applicant. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed. An exit interview was conducted, and a copy of this report was given to the applicant.the state’s words, verbatim · CDSS document, Apr 25, 2025

Type of visit: Prelicensing

On 4/11/25 at 1:00 P.M. Licensing Program Analysts (LPAs) Cynthia Tamayo and Kevin Gould arrived at Sacramento Senior Living III for the purpose of conducting a change of facility ownership pre-licensing inspection. LPAs met with Licensee, Salote Lewis, and Administrator, Tevita Kaloulasulasue, and together conducted a tour of the home. There are currently four resident in care. The facility has a fire clearance for 6 non-ambulatory clients. LPAs 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; living and dining room and outdoor areas. LPAs observed the facility to be free of odor and clean. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPAs observed resident bathroom vanities are in need of repair. Licensee informed maintenance for the bathroom fixtures are scheduled to be completed by 4/25/25. LPA Tamayo observed the facility thermostat is measured at 80*F which is within the regulation of 68*F to 85*F. Report continues on 809-C. LPA measured the water temperature, temperature measured at 108.1 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. LPAs 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. LPAs observed an operating telephone (916-509-9693) available but does not have voicemail enabled, Licensee informed she will replace the land line phone with voicemail capability. LPAs observed emergency exit plan and complaint poster PUB 475 posted in the facility. Applicant was informed that there can’t be any changes in the physical plant and must adhere to the submitted facility sketch. At the time of inspection, the facility has not met all requirements to be licensed at this time. The following corrections are required to be completed prior the department approving this location to be licensed: Pool fence must be able to be locked. all bedroom and bathroom drawers and cabinets must be in working order, easily opened and closed and not fall out when pulled out. A pre-licensing follow up appointment has been made for 4/25/25 at 9:00 A.M.An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 Interview Method: Telephone interview On 3/26/2025, applicant/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/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, Mar 26, 2025