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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701508
Report Date: 05/22/2026
Date Signed: 05/22/2026 11:36:01 AM

Substantiated


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
03/12/2026 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20260312153303
FACILITY NAME:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR:BULOU DRANICA MATAMADUAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(702) 629-0201
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
05/22/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Apakuki Nawasa, Facility ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not ensure resident's medical needs are met
INVESTIGATION FINDINGS:
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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.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
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 3
Control Number 27-AS-20260312153303
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: SENIOR GUEST HOME
FACILITY NUMBER: 342701508
VISIT DATE: 05/22/2026
NARRATIVE
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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.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260312153303
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: SENIOR GUEST HOME
FACILITY NUMBER: 342701508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2026
Section Cited
CCR
87465(a)(1)
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(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:
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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
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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.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3