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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 06/23/2026
Date Signed: 06/23/2026 10:54:48 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211145346
FACILITY NAME:SACRAMENTO SENIOR LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
06/23/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Facility Staff Netani TuivuTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
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On 06/23/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Netani 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, and records review. On 2/13/2026 LPA Hughes conducted a visit to the facility and spoke with facility staff (S1) who stated that they have not seen excluded individuals (E1) and (E2) inside of the facility. Interview with 3 out of 4 residents stated that they have not observed the excluded individuals inside of the facility. 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.

Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211145346

FACILITY NAME:SACRAMENTO SENIOR LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
06/23/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Facility Staff: Netani TuivuTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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On 06/23/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Netani 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 Administrator is not present at the facility for a sufficient amount of time.
It was alleged that the administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with facility staff, residents, and records review. On 2/13/2026 LPA Hughes conducted a visit to the facility and spoke with facility staff (S1) who stated that the facility administrator is present in the facility a few times per week. Interview with 3 out of 4 residents indicated that while they were aware of the administrator, it was reported the administrator was present only occasionally and was not frequently observed at the facility.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260211145346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SACRAMENTO SENIOR LIVING II
FACILITY NUMBER: 342701248
VISIT DATE: 06/23/2026
NARRATIVE
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On 05/29/2026 LPA Hughes requested updated LIC 500 Personnel Reports from the administrator to verify staffing and administrator presence; however, the requested records were not provided. This was observed not in compliance with Title 22 regulation 87405, 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.

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.
 
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211145346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO SENIOR LIVING II
FACILITY NUMBER: 342701248
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2026
Section Cited
CCR
87405(a)
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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… and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...
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The licensee will submit a statement of acknowledgement of the regulation cited. Additionally, the licensee will designate a facility administrator approved by CCLD, update the facility LIC 500 Personnel Report, and LIC 308 Designation of Facility Responsibility. Licensee will email administrator..
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This requirement was not met as evidenced by:
The licensee did not ensure a qualified facility administrator was present at the facility as required. Interviews revealed that the administrator was not present at the facility for the minimum required hours necessary to oversee facility operations.
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documents, LIC 308, LIC 500 to LPA by 06/29/2026.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211145346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SACRAMENTO SENIOR LIVING II
FACILITY NUMBER: 342701248
VISIT DATE: 06/23/2026
NARRATIVE
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Allegation: Staff are forging resident documents.

It was alleged that staff are forging resident documents. This investigation consisted of records review. On 2/13/2026 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. 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.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5