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Type of visit: Case Management - Deficiencies

On 08/26/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a recent incident report that was sent in for an elopement. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator, Bulou Matamadua (also known as Dede Nawasa). The Administrator was not present so care staff contacted her by phone and the Administrator arrived approximately 20 minutes later. A brief interview followed. According to the incident report sent on 8/22/26, on 08/08/26, Resident (R1) had been up all night and after encouragement from staff, went to bed at 3:00 PM. Staff looked in on R1 at 6:00 AM but did not want to disturb R1 as they still appeared to be sleeping. When staff went in to administer medication at 7:00 AM, they learned that R1 had stacked pillows and clothes under their blankets so they would appear to be sleeping. The report goes on to state that the Administrator arrived 10 minutes later and drove around in search of R1. After searching for 1 hour, the Administrator contacted the local police. R1 told a good samaritan where they lived and that person came to the care home to let the Administrator know where R1 was. Both the Administrator and the police arrived at a local business to pick up R1 who was ready to go home at that point. When LPA interviewed R1 in their room, they stated that they had snuck out. R1 could not remember which door they exited; whether it was the exit from their room to the yard, or through the front door. LPA checked the door in R1's room, and although it was alarmed, the alarm was not activated. When this LPA entered the room, she also observed a lighter on the floor. Per R1's LIC 602, dated 12/31/25, they were not to have access to "matches and similar items" and they were also "unable to leave the facility unassisted" These deficiencies have been cited on the LIC 809D page. In addition to those two deficiencies, the another citation was delivered for not meeting reporting requirements as incident reports for occurrences on 08/08/26, 08/09/26 were sent to Community Care Licensing on 08/22/26 and another report for an incident that occurred on 08/17/26, was sent in on 08/26/26. LPA reviewed reporting requirements with the Administrator. During this visit, this LPA provided assistance with regard to completing an application for a license for an Residential Care Facility for the Elderly. According to the California Code of Regulations, Title 22, civil penalties were assessed today for the elopement. A copy of this report was provided, along with APPEAL RIGHTS and an exit interview was conducted with the Administrator.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 84711(a) · Plan of correction due date: Aug 27, 2026

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... The Licensee did not ensure that the above regulation was met as evidenced by: Based on record review and interviews with R1 and the Administrator, R1 was able to elope from the facility without staff knowledge. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Administrator set the door alarms while LPA was present at the facility. The Administrator stated she will conduct an in-service where she will instruct staff on conducting more frequent checks on residents. Staff will sign off on training and this will be emailed to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(b) · Plan of correction due date: Aug 27, 2026

Storage Space and Access (b) Residents may have access...for personal use unless there is documentation ...that indicates the resident's or other residents’ safety would be at risk... The Licensee did not meet the above requirement as evidenced by: LPA observed a lighter on the floor of R1's room. This posed an immediate threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Administrator locked the lighter in the medication cabinet for safe keeping and will instruct staff (during the same in-service) to assist with lighting R1's cigarettes and then to promptly relock it in the medication cabinet when done. Staff will also ask for any lighters when R1 returns from outings.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Sep 4, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The Licensee did not meet the above requirement as evidenced by: Based on record review and an interview with the Administrator, 3 incident reports were sent to CCL past the 7 day requirement. This posed a potential threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Due to lack of supervision, resident eloped.

On 06/04/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. Person that greeted LPA stated that they were not staff and were just helping out. LPA had person call the Administrator Bulou Matamadua. Matamadua explained that they were at work and would not be off until 3:00 PM. LPA asked who their Designee was as the person at the facility was not staff and should not have been left alone with residents in care. Admistrator said they were staff and had a file at the facility. The Administrator also stated that they would be sending their House Manager to the facility. LPA asked if the House Manager was the Designee, Administrator said no, not yet. LPA stated they would send an LIC 308 and that it should be completed and returned by the close of business today. House Manager/Designee, Apakuki "Kuki" Nawasa arrived and an interivew followed. LPA learned that the person present at the facility was background cleared and had been in training. Nawasa explained Substantiated that staff (S1) may not have been aware that they were staff and had completed their training. LPA reviewed S1's file and noted a lack of documentation regarding training. LPA provided technical assistance regarding what training should cover and how it should be documented. This deficiency will be cited on a case management following this visit. Nawasa stated that he did complete the RCFE Administrator's course and has his certificate and would be restructuring his training and then retraining all staff. With regard to the allegation, "Due to lack of supervision, resident eloped." During an interview with Nawasa, this LPA learned that R1 eloped though the gate in the yard. If there had been adequate supervision, this would not have happened. The Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. According to the California Code of Regulations, Title 22, any other deficiencies will be cited in a case management following this visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with the House Manager, Nawasa.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260602154338

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 5, 2026

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... The Licensee did not ensure that the above regulation was met as evidenced by: Per the House Manager, R1 eloped form the back yard. This posed an immediate threat to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Nawasa stated that they would develop a new training program that woudl follow the regulations and retrain all staff. An outline of the training and a schedule will be submitted to licensing by the close of business tomorrow 06/05/26. These materials will be sent to CCLASCPSacramentoSouthRO@dss.ca.gov or Fax to (916) 263-4744

Type of visit: Case Management - Deficiencies

On 06/04/26, Licensing Program Analyst (LPA) Kimberly Viarella made an case management visit to this facility to follow-up on deficiencies observed during the complaint investigation # 27-AS-20260602154338 that was conducted earlier today. * LPA observed that R1 had an outdated LIC 602. Regulations require annual updates or whenever a change of condition has been observed. medical professional. This deficiency has been cited on the LIC 809D page. * LPA learned through an interview with the House Manager that R1's mental state had changed since they were first admitted. Licensee did not provide appropriate assistance to R1 when they noted change in R1's mental state or deterioration of mental ability and did not ensure that these changes were documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This deficiency was cited on the LIC 809D page. * LPA observed that staff training did not contain all of the required topics and documentation did not include all of the required components. These deficiencies have been cited on the LIC 809D page. * LPA observed that R1 did not have a signed admission agreement for the facility in which they currently reside. This deficiency has been cited on the LIC 809D page. * LPA observed that staff health records did not include the name of staff person assessed. LPA provided technical assistance. According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Nawasa.the state’s words, verbatim · CDSS document, Jun 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(h) · Plan of correction due date: Jun 30, 2026

Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. The Licensee did not meet this requirement as evidenced by: Based on record review, R1's last LIC 602 was dated May or 2024. This poses/ed an immediate threat to the heatlh, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee will provide documentation by the close of business tomorrow on securing a primary care physician for R1 and scheduling an appointment. This information will sent to CCLASCPSacramentoSouthRO@dss.ca.gov or faxed to: (916) 263-4744

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Jun 5, 2026

Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, ...and that appropriate assistance is provided... The Licensee did not ensure that the above requirement was met as evidenced by: Licensee did not provide appropriate assistence to R1 when they noted change in R1's mental state or deterioration of mental ability the licensee did not ensure that these changes were documented and brought to the attention of the resident's physician and the resident's responsible person, if any.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: The Licensee will conduct a training on this area and the materials and a date for training will be submitted to licensing by the close of business on 6/5/26 the email or fax above.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jul 16, 2026

Personnel Requirements: All RCFE staff who assist residents... shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 The Licensee did not ensure that the above regulation was met as evidenced by: requirement was met as evidence by: Based on document review and and interview with the House Manager, training was incomplete and not documented properly. This poses a potential threat to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee will ensure that all training will be completed and all necessary documents will be on fie for Licensing to review by 07/16/26. Licensee to send training materials and signature sheets for all participants but the date above. These will be faxed to (916) 263 4744.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(d) · Plan of correction due date: Jun 19, 2026

Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative... The Licensee did not ensure that the This requirement was not met as evidence by: Based on document review, R1 did not have a signed agreement to be living in this facility. This posed a potential threat to the health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee will ensure that each resident has a signed admission agreement with all necessary components. This will be completed and copies of each will be faxed to (916) 263 4744. by the close of business on 6/19/26

Allegation investigated: Staff did not prevent residents from engaging in a physical altercation.

On May 22, 2026, Licensing Program Analyst (LPA) Arvin Villnueva arrived unannounced to this facility to conduct a follow-up complaint visit and deliver findings of the above allegation. LPA Villanueva intially met with staff on duty, Elgeata Crooks (S1) and stated the purpose of the visit. Present during this visit were 4 residents with 2 staff on duty. Upon arrival, LPA was greeted by S1 and stated she is helping today and that two residents were out for a walk with Apakuki Nawasa (S2). S2 arrived shortly after with two residents from their walks. S2 confirmed he is still the facility manager. It was alleged that staff did not prevent residents from engaging in a physical altercation. The investigation into this allegation consisted of interviews and record reviews. {1 of 2} Unsubstantiated Based on interviews conducted with three staff members, all denied that any residents had been involved in a physical altercation. Staff reported that one resident has a history of alleging that they were hit or involved in fights with others in the home. Interviews were also conducted with five residents, all of whom denied being involved in any physical altercation with other residents. Additionally, all five residents denied witnessing any physical altercations involving other residents. A review of R1’s pre-appraisal, daily notes, and Needs and Services Plan indicates that R1 has a history of reporting injuries allegedly caused by others in the home. Due to the conflicting information obtained, it could not be determined whether staff failed to prevent residents from engaging in a physical altercation. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted with S2 and a copy of this report and appeal rights were provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, May 22, 2026 · control 27-AS-20260309153949

Allegation investigated: Staff do not ensure resident's medical needs are met

On May 22, 2026, Licensing Program Analyst (LPA) Arvin Villnueva arrived unannounced to this facility to conduct a follow-up complaint visit and deliver findings of the above allegation. LPA Villanueva intially met with staff on duty, Elgeata Crooks (S1) and stated the purpose of the visit. Present during this visit were 4 residents with 2 staff on duty. Upon arrival, LPA was greeted by S1 and stated she is helping today and that two residents were out for a walk with Apakuki Nawasa (S2). S2 arrived shortly after with two residents from their walks. S2 confirmed he is still the facility manager. It was alleged that staff do not ensure resident’s medical needs are met. The investigaiton into this allegation consisted of interviews with relevant persons and record reviews obtained from the facility. {1 of 2} Substantiated Based on interviews conducted, it was determined that R1 was admitted to the facility on 08/01/2025 with no documented indication of behaviors suggesting a tendency to leave the facility. It was further learned that between January 2026 and March 2026, R1 eloped from the facility unassisted on approximately six occasions, during which outside agencies located the resident several blocks away from the facility. An interview with the facility administrator revealed that the facility had identified that R1 began exhibiting elopement behaviors and that the resident was subsequently sent to the hospital due to the facility’s inability to adequately care for them. A review of the resident’s Needs and Services Plan revealed that no updated assessment was conducted after the facility identified a change in R1’s condition. The most recent Needs and Services Plan on file was completed in August 2025. Additionally, a review of R1’s Client Daily Checklist indicated that the resident had no history of elopement, however, the facility administrator acknowledged that R1 consistently elopes from the facility. Further interview with the facility administrator revealed that staff had observed ongoing behavioral changes in R1 but had not contacted the resident’s physician or responsible party to address the resident’s changing needs. Based on the information obtained, the facility staff do not ensure that R1’s medical needs were met. As a result of this investigation, the Department 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. An exit interview was conducted with S2 and discussed plan of corrections and appeal rights. A copy of this report along with appeals rights were provided to the facility at the end of this visit. {2 of 2}the state’s words, verbatim · CDSS document, May 22, 2026 · control 27-AS-20260312153303

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 29, 2026

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This is not met was evidenced by: Based on interview and record review, the licensee did not ensure that they assisted R1 with medical are appropriate to their current condition and needs of the resident. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Per discussion, the facility manager agreed to create a plan in place to ensure their residents’ medical needs are met. Submit the plan by end of business day on May 29, 2026 to Arielle.Pascua@dss.ca.gov

Allegation investigated: Staff did not provide adequate supervision to residents in care

On 05/04/2026, Licensing Program Analyst (LPA) Arielle Pascua and Cosumnes High Utlizier Specialist (CHUS), Eddie Rachsein arrived to this facility unannounced to conduct a complaint visit. LPA Pascua met with Staff Member, Estia Nawani and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Shortly after, LPA Pascua met with House Manager, Apakuki Nawasa and Facility Designated Administrator (FDA), Bulou Dranica Matadua. Current census was 4. It was learned that 1 resident was out at the hospital at this time. During the course of this visit, LPA Pascua conducted a tour of the facility and reviewed facility records. Based on the information gathered, R1 eloped from the facility on six separate occasions in January 2026, as well as on 02/15/2025 and 04/08/2025. Interviews further revealed that on one of these occasions, R1 was found at a major intersection on the same day. During today’s visit, LPA Pascua observed R1 leaving the facility and had to alert staff after the resident exited the premises. A review of the resident’s physician report indicates that R1 is not able to leave the facility unassisted. Substantiated Based on the information gathered, staff did not provide adequate supervision to the residents in care. 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. An immediate Civil Penalties of $500 are being issued today for Section 87411(a). Licensee was provided a copy of their rights (LIC9058) and their/or representative's signature acknowledges receipt of these rights. An exit interview was conducted with Apakuki Nawasa and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026 · control 27-AS-20260302155019

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 5, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This is not met as evidenced by: Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 has eloped from the facility approximately 8 times within this year and is not able to leave unassisted. This poses an immediate health and safety risk to the R1 in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: An immediate civil penalty of $500 was issued for violation of this Section. Licensee will provide a statement of correction, along with proof of training from an outside vendor for no less that one hour in duration regarding AWOL procedures. Licensee shall also update AWOL procedures. A copy of training and these procedures shall be provided to to the LPA by POC date.

Type of visit: Case Management - Incident

On 05/04/2026, Licensing Program Analyst (LPA) Arielle Pascua and Cosumnes High Utlizier Specialist (CHUS), Eddie Rachsein arrived to this facility unannounced to conduct a complaint visit. LPA Pascua met with Staff Member, Estia Nawani and explained the purpose of the visit. The purpose of this visit was in response to the complaint visits conducted on this day and the observations made. Shortly after, LPA Pascua met with House Manager, Apakuki Nawasa and Facility Designated Administrator (FDA), Bulou Dranica Matadua. Current census was 4. It was learned that 1 resident was out at the hospital at this time. During the course of this visit, LPA Pascua conducted a tour of the facility and reviewed facility records. While touring the kitchen, it was observed that the facility did not maintain an adequate two-day supply of perishable food. LPA Pascua observed an empty jar of pickles, an empty jar of salsa, a half-gallon of milk, a locked box, one mandarin fruit cup, mayonnaise, a bowl containing an unknown substance, and a package of turkey meat. When asked how often the facility obtains food, staff stated that additional food was kept locked in the garage due to residents eating during the night. LPA Pascua continued the tour into the bedrooms and observed that, in one bedroom, a bed was blocking the double exit doors. After moving the bed, LPA Pascua noted a lock installed at the top of the door that would prevent the door from being easily opened. During the tour of the garage, LPA Pascua observed a sign indicating that residents were not permitted to enter the area. Upon entry, an air mattress was observed along with personal items, including chargers, a pillow, and a blanket. A second refrigerator was also present, however, it contained only a limited supply of food, including a box of pancakes, waffles, two gallons of milk, one chicken, cheese, and butter. The tour continued to the backyard, where it was observed that the back gate had been modified with a MagnaLatch child safety lock. LPA Pascua was unable to open the gate easily. In addition, a tour of the facility bathrooms was conducted, during which it was observed that both resident toilets were clogged at the time of LPA Pascua’s visit. Based on today's visit, the facility is being cited for deficiencies noted in LIC809-D. Additionally, the facility is hereby assessed a civil penalty of $500 each for Sections 87203 and 87202(a) for Fire Safety and Fire Clearance. Technical Support Program was discussed during this visit. An exit interview was conducted and a copy of this report along with appeals rights were provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 5, 2026

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This it not met as evidenced by: Based on observation the facility did not ensure that exit gate and bedroom door were not locked. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The facility shall remove the locks from the back gate and bedroom door. The licensee shall also submit a written statement of correction and ensure that staff complete at least one hour of fire safety training conducted by an outside vendor. Documentation of the completed training shall be provided to LPA Pascua by the plan of correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87202(a) · Plan of correction due date: May 5, 2026

a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This is not met as evidenced by: Based on observation, the Licensee did not ensure that the facility garage was cleared for staff use. LPA Pascua observed an air mattress along with personal items in the garage. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The facility shall remove the air mattress from the garage. The licensee shall submit a fire clearance request to the Department to update the facility’s fire clearance, reflecting changes to the garage and staff occupancy. The licensee shall also provide a written statement of correction and ensure that staff complete a minimum of one hour of fire safety training conducted by an outside vendor. Documentation of the completed training shall be submitted to LPA Pascua by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: May 5, 2026

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This is not met as evidenced by: The licensee did not ensure there was a sufficient 2 day perishable food supply at the facility at the time of this LPAs visit. This poses an immediate, health,safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The licensee shall submit to LPA Pascua a plan to ensure the facility maintains an adequate two-day supply of perishable food. Copies of receipts and photographs verifying compliance shall be provided to the LPA by the (POC) due date. Photographs and receipts shall be sent to the LPA weekly until 06/04/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: May 29, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This is not met as evidenced by: Based on observation, the liensee did not ensure that the toilets used for resident used were unclogged. This poses a potential health,safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The licensee unclogged the toilet at the time of this visit. The licensee shall submit to LPA Pascua a written acknowledgment of this regulation, along with a plan to ensure that the facility maintains fully functioning toilets.

Allegation investigated: Due to neglect/lack of care and supervision, residents had access to illegal drugs. Staff did not prevent residents from eloping from the facility.

On 03-11-2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a follow-up complaint investigation visit and deliver findings regarding the allegations noted above. LPA met with facility manager, Apakuki Nawasa (S1) and stated the purpose of the visit. Present during this visit were 4 in care with 1 staff on duty. Throughout this investigation, the Department conducted interviews with relevant persons, including, but not limited to, staff and residents, record reveiws of relevant documents, and facility observations. Upon review and investigation of the above allegations, the Department determined the following. {1 of 4} Substantiated Allegation – Due to neglect/lack of care and supervision, residents had access to illegal drugs. The investigation into this allegation consisted of interviews and record reviews. Based on an interview with a witness (W1), on 11/14/2025, residents R1 has been known to have methamphetamine in their possession and has distributed methamphetamine to R2. Interviews revealed that within one week of moving into this facility, R1 displayed behaviors consistent with drug use. R1 went on outings, and returned to the facility erratic, grinding their teeth, swearing, and having red eyes. According to one facility staff member, R1 would return to the facility appearing high on drugs and bringing back “crystal rock.” Staff interviews confirmed they had not seen R1 with drugs but seen R1 with a “pipe.” Records for R1 show a history of substance abuse. R1’s Medical Assessment dated 8/15/2025 documented that R1 was diagnosed with substance abuse disorder and polysubstance self-abuse. The assessment also stated that R1 was able to leave the facility unassisted. R1’s Needs and Services Plan dated 8/13/2025 did not include a plan for how the facility would manage or address R1’s illegal substance abuse. R1’s court documents dated 8/12/2025 showed R1 had a scheduled court appearance for unlawful possession of methamphetamine, criminal threats, and felony-level elder abuse. Facility daily notes from 10/10/2025 to 11/11/2025 were also reviewed. On 11/10/2025. R1 told staff that they went to buy drugs and said they had shared the drugs with other residents in care. On 11/11/2025, staff documented that R1 was giving methamphetamine to other residents around 3:00 AM. It was also noted that R1 and R2 left the facility at around 3:30 AM. Police records dated 11/12/2025 further confirm concerns of drug use. Officers responded to the facility after receiving a report that a resident was possessing and distributing methamphetamine. Staff on duty reported that R1 admitted to using methamphetamine and giving it to two other residents. During a search of R1’s bedroom, officers found burnt foil and a plastic blue straw, which are commonly used to ingest drugs such as methamphetamine, heroin, or fentanyl. R1 was taken into custody for possession of drug paraphernalia and stated that they used the foil and straw to smoke drugs. The facility’s house rules state that possession of illegal drugs is prohibited. However, records and interviews show that R1 continued to leave the facility, obtain drugs, return to the facility while under the influence, and share drugs with other residents. Based on the interviews, records reviewed, and police report, the allegation that residents had access to illegal drugs due to neglect and lack of supervision is substantiated. {2 of 4} Allegation - Staff did not prevent residents from eloping from the facility. The investigation into this allegation consisted of interviews and record reviews. Interview with witness, W1, who reported that on 11/10/2025, an unnamed resident in care eloped from the facility. W1 further stated that 2 facility staff left the facility for approximately 20 minutes to look for the resident, leaving the facility without any staff present. On the same day, another resident (R4) eloped from the facility at approximately 11:35 AM. W1 reported that facility staff did not report that R4 was missing to law enforcement. On 11/12/2025, R4 was located at a location approximately seven miles away from the facility. Interview with a resident’s family member stated they received a call from a facility staff informing them that R2 had eloped from the facility without supervision. Interviews and record reviews revealed that R2 was unable to leave the facility without assistance. Review of facility notes revealed that on 10/11/2025 confirmed that R1 had shared drugs with R2 and other residents in care. The facility notes also revealed that on 11/11/2025, R1 and R2 left the facility at around 3:30 AM and R2 returned to the facility at around 4:00 AM. Police records from the Elk Grove Police Department were also reviewed. According to Summary Report #25-004128, on 06/20/2025, Officer responded to the facility after resident R3 was reported missing at approximately 10:00 AM. after leaving the facility. Additional information was obtained during another complaint investigation conducted on 12/17/2025 (Complaint# 27-AS-20251208152635). During that investigation, interviews and record reviews revealed that resident R3 had another elopement incident on 12/15/2025. Staff on duty reported that on the morning of 12/15/2025, during breakfast, R3 became angry. Staff stated that she was the only staff member on duty at the time. While taking the garbage outside, staff observed R3 outside on the sidewalk. Staff stated that R3 walked past her and continued walking down the street. Staff attempted to verbally redirect R3 but was unsuccessful. Staff then instructed another resident, R5, to follow R3 while she returned inside the facility to contact the administrator, Bulou Matamadua, to report the incident. Staff reported that the administrator instructed her to call 911. Staff stated that law enforcement eventually located R3. Record reviews for R3 revealed that R3 was assessed as unable to leave the facility without assistance and required staff supervision, including supervision when using the bathroom. Based on interviews and record reviews, multiple residents who were assessed as unable to leave the facility without assistance were able to exit the facility without staff supervision. Additionally, there were incidents where the facility was left without staff present, and in one case, staff instructed another resident to follow an eloping resident instead of directly supervising the resident. Based on the evidence obtained during the investigation, the allegation that staff did not prevent residents from eloping from the facility is substantiated. {3 of 4} Note: a finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. An immediate Civil Penalties of $1500 are being issued today. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, the Department will return at a future date to assess the civil penalties. Licensee was provided a copy of their rights (LIC9058) and their/or representative's signature acknowledges receipt of these rights. An exit interview was conducted with Apakuki Nawasa and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 27-AS-20251112124819

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 23, 2026

Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the regulation cited above. Staff did not properly supervised resident with known substance abuse history and did not implement plan to manage this behavior which allowed drug possession and distribution in the facility. This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Per discussion, Administrator agreed to submit the following written plan: (1) Risk Mitigation on Substance Use and Contraband Policy; (2) Plan for Incident Reporting that includes suspected illegal drug possession/distributioin; (3) Conduct staff training for Care & Supervision requirements under Title 22, Recognizing substance use behaviors, notifying law enforcement and documentation standards. Plan to be submitted by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Mar 23, 2026

Basic services requirements Being aware of the resident’s general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the regulation cited. Multiple elopements. One staff did not follow resident when he eloped. Staff left facility to look for eloped resident, leaving the facility without staff supervision. Resident is able to obtain illegal drugs when out in the community This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Per discussion, Administrator agreed to submit the following written plan: (1) Risk Mitigation on Substance Use and Contraband Policy; (2) Plan for Incident Reporting that includes suspected illegal drug possession/distributioin; (3) Conduct staff training for Care & Supervision requirements under Title 22, Recognizing substance use behaviors, notifying law enforcement and documentation standards. Plan to be submitted by POC due date.

Type of visit: POC

On 1/16/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct a Case Management - Plan of Correction (POC) visit. LPA met with facility manager, Apakuki Nawasa (S1) and stated the purpose of the visit. Upon arrival, S1 was the only staff on duty, with 4 residents in care. Based on today's visit, it was determined and confirmed that licensee did not submit one Plan of Correction that was issued on 1/9/2026. The facility was cited with CCR 87465(a)(4) A plan for incidental medical and dental care shall be developed by each facility…The licensee shall assist residents with self-administered medications as needed.This citation was due on 1/10/2026. The licensee did not comply with the terms of the POC-by-POC due date. Facility is hereby being assessed a civil penalty in the amount of 100$ per day is assessed for the failure to correct, from the date of 1/10/2026 to today 1/16/2026, a total of $800. A fine will continue to accrue in the amount of 100$ per day until the POC is implemented and proof of correction is submitted to the department for review. Appeal rights were given, a copy of the civil penalty was given to S1, a copy of the report was read and given to S1. an exit interview was held.the state’s words, verbatim · CDSS document, Jan 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 17, 2026

Created this page by mistake. See 9099-D dated 1/9/2026. This page was not provided to facility.the state’s words, verbatim · CDSS document, Jan 16, 2026

Type of visit: Case Management - Deficiencies

On 1/9/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management visit. LPA initially met with staff on duty, Carlos Samayoa (S1), and stated the purpose of the visit. One of the facility manager, Apakuki Nawasa (S2), was notified. S2 is unable to come to the facility immediately and designated S1 to assist with the visit. Present during this visit were 5 residents in care with one staff on duty (S1). The Administrator Bulou Matamadua (AD), arrived at 11:45am. During this visit, a resident (R4) had an unwitnessed fall. Prior to the fall, S1 was in the kitchen preparing their lunch meal. LPA heard a loud thud sound and observed R4 lying on the bathroom floor. LPA observed 2 small pieces of countertop tiles on the floor next to R4's head. R4 seizured for about 10 - 15 seconds. S1 called 911 and they arrived about 5 minutes later. LPA overheard S1 reporting to the Emergency Personnel that R4 ran out of seizure medication 2 - 3 days ago. R4 was assessed by Emergency Personnel with no visible injuries. Review of R4's medications confirms R4's medication bottles were empty. Review of R4's medication administration record confirms R4 was out of seizure medications on 1/7/2026. Other medications ran out beginning 1/5/2026. R4 was taken to the hospital for evaluation and for seizure medication. Interview with AD revealed that R4 currently do not have an established primary physician but did not plan accordingly to ensure R4 received their medication refills. Purpose of this visit is to obtain additional files for Complaint# 27-AS-20251112124819. LPA obtained copy of resident files belong to R1 and R2 for further review. LPA obtain copy of facility files, including staff schedule for November 2025, resident roster from November to present, and facility policy on resident drug use and resident rules. R2's documents were not at this facility during this visit. The facility manager had to go to another facility to obtain R2's documents. Purpose of this visit is to recite deficiencies from Complaint# 27-AS-20251208152635. LPA is reciting the facility for not submitting the Plan of Corrections (POC) set on 12/17/2025. Facility was cited for CCR 87464(f)(1) Basic Services and it was due 12/18/25. Facility was also cited for CCR 87468.1(a)(2) Personal Rights of Residents in All Facilities and it was due 12/24/25. The Department did not receive these POCs. Purpose of this visit is to cite deficiencies observed during complaint visit on 12/17/2025 (Complaint# 27-AS-20251208152635). During a visit on 12/17/25, LPA observed a door knob lock on a chair by the front door. LPA asked staff (S3) regarding the door knob lock and stated that they (staff) use a door knob lock to secure the front door knob to prevent residents from opening the front door and going outside. It is a door knob cover with combination to unlock. S3 demonstrated to LPA how they use this device. During today's visit, LPA observed the door knob lock on a dining table located in the living room area. This is a repeat violation. The facility was cited for this violation on 9/11/25 and will be assess a civil penalty of $1000 for repeat violation during this visit. During a complaint visit on 12/17/2025, LPA discovered, through record review and interviews, R4 had an elopement incident occurred on 12/15/25 and emergency hospitalization due to psychiatric problem on 12/1/25. Through LPA's verification, the Department did not receive these incident reports. Based on today's visit, the facility is being cited for deficiencies noted in 9099-D. Additionally, the facility is hereby assessed a civil penalty of $1000 for repeat violation. Facility is hereby assessed additional immediate civil penalty of $500 not ensuring resident received their seizure medication timely, which resulted in seizure and fall. Plan of Corrections and due dates were discussed during the exit interview. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jan 10, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. Staff are still placing a door knob cover equipped with combination lock on the knob of the front door to prevent residents from leaving without supervision.This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Corrected on site: Administrator discarded the door knob lock in the trash can. Facility administrator agrees to retrain staff. Proof of retraining shall be submitted to the Department by 1/16/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(1) · Plan of correction due date: Jan 10, 2026

Reporting Requirements: A written report shall be 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 is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the regulation cited above. LPA discovered that a resident (R3) had a hospitalization on 12/1/25 due to psychiatric issue and same resident eloped on 12/15/25. The Department did not receive incident reports for these incidents. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agrees to submit a written statement of understanding of the regulation related to reporting requirement. Statement shall be submitted tomorrow 1/10/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 10, 2026

Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Based on interviews, by admission of the facility manager, there were 2 instances where resident was not adequately supervised: one was when was reported by neighbor urinating on the street; and another instance where resident eloped, and staff did not follow. Record reviews showed is not able to leave the facility unassisted. This poses immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Per discussion, the licensee or its designee will submit a statement of understanding regarding the cited regulation. Written statement must be submitted by tomorrow, 1/10/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Jan 16, 2026

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is not met as evidenced by: Based on interviews, by admission of facility manager, staff yelled at residents and deemed it inappropriate. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Per discussion, the administrator will conduct a staff training related to Personal Rights and proper communication with residents. Proof of training must be submitted to the Department by 1/16/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 10, 2026

A plan for incidental medical and dental care shall be developed by each facility…The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observations, record reviews and interviews, the licensee did not comply with the regulation cited above. Facility staff did not ensure that R4 received their medication refills on time, including their seizure medication, which resulted in R4 sustaining a seizure and fall during today’s visit. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agreed to submit a written plan to ensure all residents in care receive their medication on time and ensure residents' medications do not run out. Plan shall be submitted by 1/10/2026.

The state marks this report as 13 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff yell at residents in care. Staff did not provide adequate supervision to residents in care.

On 12/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct the initial complaint visit regarding the allegations noted above. LPA initially met with staff on duty, Laisa Peters (S1) and stated the purpose of the visit. S1 notified the Administrator, Bulou Matamadua, of the visit. Apakuki Nawasa, identified as Bulou's husband, arrived shortly after. Upon entrance, LPA was greeted by S1 and interview was immediately conducted. Present during today's visit were 4 residents in care with 1 staff on duty. LPA interviewed S2 after arrving at the facility. LPA conducted facility obsevation, including but not limited to, the interior of the facility, backyard, and front yard. LPA conducted staff interviews and record reviews of resident and staff files. LPA also conducted interviews with witnesses. Also during this visit, LPA returned the files that was removed earlier today for the purpose of copying relevant documents at the Regional Office. Files were handed to S2. Substantiated Allegation: Staff yell at residents in care. The investigation into this allegation consisted of observation, interviews and record reviews. When staff were interviewed, they admitted that staff sometimes get into “heated arguments” with residents. Staff explained that during these arguments, they raise their voices at residents to “get their attention.” S2 also admitted that he has seen staff yell or raise their voices at residents. He said he believes this behavior is not appropriate. S2 stated that when he sees this happen, he gives staff verbal reminders about how to speak to residents in a respectful way. However, he also admitted that he has not documented any of these in-service trainings. S2 said that staff need to improve how they communicate with residents and that they need more training. Interviews with witnesses confirmed hearing yelling coming from this facility at times but cannot confirm if the yelling is from by staff or residents. Staff interviews confirmed that yelling or raising voices at residents does happen. Staff do not see it as a problem, while S2 does. S2’s lack of documentation shows that the facility has not been keeping proper records of training or corrective actions. This supports the concern that staff are not consistently using appropriate communication with residents. Based on all the information gathered, there is enough evidence to show that staff have yelled at residents, therefore, allegations are substantiated *************************************************** Allegation: Staff did not provide adequate supervision to residents in care. An investigation was completed after a complaint was made that staff were not giving residents proper supervision. Interviews were done with the S2 and staff, and resident records were reviewed. During an interview, S2 said he was not aware of any residents defecating in the backyard or in public. He did say that one resident (R1) has a history of inappropriate defecation inside their room, but not outside the facility. However, S2 also admitted that about two weeks ago, another resident (R2) urinated in a street gutter in front of the facility without supervision. S2 learned about this incident from a neighbor, who verbally reported it to S2. S2 further admitted that R2 eloped from the facility about 2–3 days ago. He explained that staff (S1) saw R2 walking down the street but did not follow R2. Instead, staff called 911. Verbal redirection made to R2 was unsuccessful. A review of R2’s records showed that R2 is assessed as a resident who should not leave the facility without staff assistance. This means staff were expected to closely supervise R2 to prevent them from leaving on their own. During an interview with staff (S1), S1 confirmed that R1 has a pattern of inappropriate defecation, including making messes in their room and bathroom. S1 also stated that R1 used to defecate in the backyard in the past. S1 also stated that R2 eloped and she stated she instructed another resident (R4) to follow R2. Interview with witnesses confirmed that there was one instance, about 2 to 3 weeks ago, where a witness observed a person urinating on the street gutter. Witness confirmed that the mentioned resident was unsupervised. The witness’s description of the mentioned the resident is consistent with a current resident in care. Based on the evidence gathered, the allegation that staff did not provide adequate supervision to residents in care is substantiated. These incidents show that staff did not provide the level of supervision needed to keep residents safe and prevent unsafe behaviors in the community. 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 S2 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 27-AS-20251208152635

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 18, 2025

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, by admission of the facility manager, there were 2 instances where resident (R2) was not adequately supervised: one was when R2 was reported by neighbor urinating on the street; and another instance where R2 eloped, and staff did not follow R2. Record reviews showed R2 is not able to leave the facility unassisted. This poses immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: Per discussion, the licensee or its designee will submit a statement of understanding regarding the cited regulation. Written statement must be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 24, 2025

87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is not met as evidenced by: Based on interviews, by admission of facility manager, staff yelled at residents and deemed it inappropriate. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: Per facility manager, he immediately conducts in-service training to staff whenever he observes staff yelling at residents inappropriately. Per discussion, the facility manager will conduct a staff training related to Personal Rights and proper communication with residents. Proof of training must be submitted to the Department by POC due date.

Type of visit: Case Management - Other

On 12/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct the open a complaint related to this facility (Complaint #27-AS-20251208152635) LPA initially met with staff on duty, Laisa Peters (S1) and stated the purpose of the visit. S1 notified the Administrator, Bulou Matamadua, of the visit. Apakuki Nawasa (S2), identified as Bulou's husband, arrived shortly after. During this visit, LPA requested copy of records. Per S2, their copy machine is not working. LPA requested to remove the following files for the purpose of copying at the Regional Office: Resident files for (R1, R2, R3, R4): files removed include, but not limited to, Admission Agreement, LIC601 LIC602, LIC603, LICE 625 Hospital visits Staff files for (S1, S3, S4, S5): files removed include: Training Records LIC500 Exit interview was conducted with S2 to inform that LPA will return these files later today. Copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Case Management - Annual Continuation

On 9/23/2025, Licensing Program Analysts, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct an annual continuation visit to continue the annual visit initiated on 9/11/2025. LPA initially met with the staff on duty (S3) and explained the purpose of today’s visit. The facility manager, Bulou Matamadua (S2), was informed of the visit and arrived at 9:55am. Present during this visit were 4 residents in care with 2 staff on duty (S2 and S3). During this visit, LPA conducted record reviews. Review of 3 of 3 resident files (R1, R2, R3) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to ensure resident files are complete and current. Medication review of 2 residents (R1, R3) include review of physician orders for over-the-counter medications and PRN records. Advisory was provided to ensure each residents have on their files: PRN authorization letter and current prescription orders. Review of 5 staff files (S1 - S5) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Advisory was provided to ensure each staff have complete records on file and omit documents unrelated to this facility. LPA also reviewed fire drill/disaster drill records; facility conducts at least quarterly drills. LPA requested a copy of current facility's Liability Insurance Certificate, LIC500 and LIC308 during this visit. DEFICIENCIES from last visit have been corrected. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Exit interview was conducted with S1. A copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Sep 23, 2025

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 9/17/2025 Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced to this facility to conduct a case management visit for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA initially met with staff on duty (S1 and S2), and explained the purpose of the visit. One of the facility manager, Apakuki Nawasa (S3), was notified and arrived shortly after. Staff (S4) is excluded as a result unrelated to this facility. LPA served notice of "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for S4 who was not present at the time of visit. S3 was advised that an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S4 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA informed S3 that S4 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion From All Facilities will be in effect as of 9/17/2025 upon receipt of the letter. A copy of the letter was given to the facility during this visit. The facility understands this is an Immediate Exclusion and has agreed S4 cannot be allowed to work, live in, and/or have contact with residents in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held with S3, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Required - 1 Year

On 9/11/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with staff on duty, Dave Valentine (S1) and stated the purpose of the visit. The designated facility manager, Bulou Matamadua (S2), was notified and arrived later during the visit. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, 4 of which may be non-ambulatory. Facility has a hospice waiver for 3 residents. Bedrooms #1-3 were approved for non-ambulatory use. Bedroom #4 is for ambulatory use only. Initial Observation: Upon arrival LPA was greeted by S1, who informed LPA that there are currently 4 residents present at this time with one staff on duty. One of the residents is currently out. LPA also observed an outside agency staff present but left shortly after. While LPA was setting up for the inspection, LPA observed S1 placed a door knob cover with a combination lock. Per S1, he placed the door knob cover because one resident has a behavior of eloping. Room temperature was at 69 degrees Fahrenheit. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 3 of 4 resident bedrooms and 2 of 2 bathrooms. LPA measured the hot water temperature in the 1 of 2 bathrooms (hallway) to be at 111 degrees Fahrenheit. Both resident bathrooms were observed to be in good repair at this time. LPA inspected the closet in the hallway and observed a cleaner (Fabuluso brand) on the shelf. This closet was unlocked and accessible to residents in care. Fire extinguisher was observed in the living room and was last inspected on 9/4/24. {809-1} Inspection of the garage: LPA observed a bed with pillows on top. Per S1 and S2, the bed was moved from a resident bedroom since the resident received a hospital bed. Further inspection of the garage, in a cupboard, LPA observed a medication container labeled Stool Softener, and it was observed to have pills in it. S2 removed the medication. LPA also observed DME equipment and other furniture/beds. According to S2, these belong to the previous licensees, and S2 still waiting for them to be picked up. Advisory was provided to clean out the garage for resident's safety. Inspection of the outdoor areas: Facility has one exit gate located at the garage side of the facility. Fence and gates were observed to be in good condition at this time. Shaded area and outdoor furniture were observed. Based on today's visit, this annual will require a continuation. The Department will return at a later date to continue the inspection. Deficiencies are being cited. Exit interview was conducted and a copy of this report and appeal rights were provided. {809-2}the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Post Licensing

On 6/26/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility to conduct their post-licensing inspection. LPA met with designated staff, Buluo Matamadua (S5), and explained the purpose of the visit. Present during this visit were 3 residents in care with Present during this visit were 3 residents in care with 2 staff on duty (S1 and S5) LPA evaluated the physical plant with S5 to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 3 of 3 resident bedrooms. Room #1, based on facility sketch, is currently shared by 2 residents. However, LPA observed one night stand between the two beds. Also in room #1, one resident drawer is in need of repair/replacement as evidenced by wood chipped off. Inside this drawer, LPA observed hygiene and grooming supplies. Per review of LIC602A, resident(s) is/are present at this facility is/are at risks if allowed to have access to these personal grooming and hygiene items. Room #1 also has its own bathroom. LPA observed hygiene and grooming products accessible to resident(s) who is/are at risks if they have access to these products. In this bathroom, LPA observed the toilet to be missing a toilet seat. Also, in room #1, the sliding screen door has been detached. Per interview with S5, one resident removed it. In room #2, LPA observed the floor at the entrance has part of it chipped off. In the bathroom at the hallway, a grab bar in front of the toilet was loose. Advisory was provided for necessary repair. Inspection of the kitchen was conducted. LPA observed knives and scissors inside one of the kitchen drawers, accessible to residents in care. The facility maintains sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water in one resident bathroom and was measured at 106 degrees Fahrenheit. Room temperature was maintained at 76 degrees Fahrenheit. Fire extinguisher was last serviced on 9/4/2024. Smoke and carbon monoxide detectors were observed. {1 of 2} Outdoor area was inspected. Facility has one side gate exit. The gate does not self lock properly. Advisory was provided to S5 to make necessary repair. Fence were observed to be in good repair at this time. Review of 4 resident files (R1, R2, R3, R4) include review of Admission Agreement, Physician Reports, Needs and Services Plan, and Ambulatory Status. Through record review and interview, a resident passed away recently and their death report was not yet submitted to the Department and it is past the reporting requirement of 7 days following the incident. Resident medications were not reviewed during this visit. Review of 7 staff files (S1 - S7) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. Per review of Guardian, it was discovered that S1 is not associated to this facility. S1 immediately left the facility and another staff (S7) who is associated to this facility came shortly after to relieve S1. Facility conducts quarterly disaster drill. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jun 26, 2025

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 10/21/24, Licensing program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to speak with the Designated Facility Administrator, Edylyne Johanna A Day (certificate # 6070622740, expiration date 05/28/26). The Administrator was not present but the LPA spoke to her on the phone and obtained permission for the Caregiver/ Designee, Marie Walker. to sign on her behalf. LPA collected the following documents for the resident in care (R1): LIC 602A LIC 625 LIC 601 LIC 603 LIC 308 to be updated and faxed to Community care Licensing by the close of business on 10/21/24 at (916) 263-4744. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 21, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a continued pre-licensing visit. LPA Valerio met with Administrator Edylyne Johanna Day, and explained the purpose of the visit. On 10/02/2024, LPA received a phone call in the afternoon from Administrator stating the corrections have been completed. The following improvements were observed: - Fence board in the backyard were replaced on the right side. - Nails sticking out on the fence located on both sides were removed - Bathroom sinks, shower floors, and faucets were cleaned. Faucet in Bedroom 1 was replaced - Wooden base board under the sink in the common area bathroom was replaced - Pee pads were removed from chairs in common areas and resident bedrooms - Lock on snack cabinet was removed - Ramps located outside of non-ambulatory rooms were secured - Shoelace attached to fan in the primary bedroom was replaced - Bedroom 1 was observed to have a ramp located outside the sliding door - An updated facility sketch was observed on the wall of the facility Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.the state’s words, verbatim · CDSS document, Oct 3, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived at the facility to conduct an announced pre-licensing visit. LPA and LPM met with Administrator/Licensee Edylyne Johanna Day, and explained the purpose of the visit. The facility has a fire clearance for 4 non-ambulatory and 2 ambulatory residents. Bedrooms 1, 2, and 3 are approved for non-ambulatory residents. Bedroom 4 is approved for ambulatory only. LPA, LPM, and Administrator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The facility is a 4-bedroom, 2 bath with 2 living rooms, 2 dining room, laundry room, kitchen, garage, and exterior area. Bedroom 1 and 4 are shared bedrooms, Bedrooms 2 and 3 are private rooms. The exterior area has a large cemented walk way, garden area, a shaded visiting area, and no obstructions to emergency exits. The fence was observed to have a self latching gate. Residents will have access to all area except garage, medication storage area, and locked cabinet storage for cleaning supplies and sharps. LPA observed no obstruction of emergency exits inside or outside of facility. LPA observed smoke detectors and carbon monoxide detectors were noted and functioning properly. The last fire drill was conducted 07/24/2024. LPA observed the area where the staff and resident files will be locked and readily available for review. LPA observed one (1) resident file and (1) staff file. LPA Valerio and licensee observed the hot water temperature in resident's bathroom at 110.1*F, within regulatory range of 105 *F and 120 *F. LPA observed food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Valerio observed a fire extinguisher in place outside of kitchen area and fully charged and within compliance. Continues on LIC 809 - C... Continued from LIC 809 The following deficiencies were observed: - Fence board in the backyard need to be secured and replaced on the right side. - Nails sticking out on the fence located on both sides need to removed - Bathroom sinks, shower floors, and faucets need to be cleaned and free from mildew and hard water deposit. - Wooden base board under the sink in the common area bathroom needs to be fixed - Pee pads need to be removed from chairs in common areas and resident bedrooms - Lock on snack cabinet need to be removed - Ramps located outside of non-ambulatory rooms need to be secured - Shoelace attached to fan in the primary bedroom needs to be replaced - Bedroom 1 needs to have a ramp located outside the screen door - An updated facility sketch needs to be submitted Component III was completed during the visit with Administrator Edylyne Johanna Day. Pre-Licensing is incomplete with deficiencies to be resolved by10/14/2024. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies.the state’s words, verbatim · CDSS document, Oct 2, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Edylyne Johanna Day (Applicant/Administrator) Interview Method: Virtual interview via Microsoft Teams On September 23, 2024, 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, Sep 23, 2024