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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701686
Report Date: 06/16/2026
Date Signed: 06/16/2026 01:44:44 PM

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-20260211112902
FACILITY NAME:GOLDEN HERITAGE SENIOR CARE IVFACILITY NUMBER:
342701686
ADMINISTRATOR:BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 667-9761
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Facility Staff: Mereoni RakulaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are forging resident documents.
INVESTIGATION FINDINGS:
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On 06/16/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Mereoni and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 5.

Allegation: Staff are forging resident documents.
It was alleged that staff are forging resident documents. This investigation consisted of resident records review. On 02/18/2026 LPA Hughes conducted a visit to the facility and obtained resident LIC 602 Physician’s Reports for 6 out of 6 residents in care. LPA Hughes reviewed the records and verified that 5 out of 6 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

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

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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 2
Control Number 27-AS-20260211112902
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: GOLDEN HERITAGE SENIOR CARE IV
FACILITY NUMBER: 342701686
VISIT DATE: 06/16/2026
NARRATIVE
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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 allegation is 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 violation occurred.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2