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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 06/04/2026
Date Signed: 06/04/2026 04:41:43 PM

Document Has Been Signed on 06/04/2026 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SENIOR GUEST HOMEFACILITY NUMBER:
342701508
ADMINISTRATOR/
DIRECTOR:		BULOU DRANICA MATAMADUAFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(702) 629-0201
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
06/04/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Apakuki "Kuki" NawasaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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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* LPA observed that R1 had an outdated LIC 602.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.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2026 04:41 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/04/2026 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2026
Section Cited
CCR
87463(h)

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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:
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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
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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.
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Type A
06/05/2026
Section Cited
CCR87466

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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:
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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.
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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.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 04:41 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 06/04/2026 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SENIOR GUEST HOME
FACILITY NUMBER: 342701508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2026
Section Cited
CCR
87411(c)

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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:
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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.
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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.
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Type B
06/19/2026
Section Cited
CCR87507(d)

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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:
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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
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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.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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