<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 02/19/2026
Date Signed: 02/19/2026 11:47:27 AM

Document Has Been Signed on 02/19/2026 11:47 AM - 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:SACRAMENTO SENIOR LIVINGFACILITY NUMBER:
342701230
ADMINISTRATOR/
DIRECTOR:		LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:6825 BENDER CTTELEPHONE:
(510) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 6CENSUS: 6DATE:
02/19/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Asena MotobulaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/19/26 at 9:15am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management deficiencies inspection to address deficiencies observed while conducting a complaint investigation.

LPA observed about 8 expired canned goods ranging from expiring in 2018 to 2025. LPA observed insecticide sitting on top of the fridge and unsecured from residents in care. LPA observed doorframe broken with a large piece missing from the door frame. Upon entering the home LPA inspected the home thermostats and observed the living room, kitchen and resident and staff room were observed to be at 66 degrees F. below the required temperature, LPA observed the temperature to be set at 83 degree and the heater is not working. LPA inspected the other thermostat and observed the temperature to be set below the required temperature of 68 degrees. LPA observed staff turn up the temperature and the heater was working in this part of the home.

Per the California Code of Regulations, Title 22, the following deficiencies are cited.

Exit interview conducted and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
Document Has Been Signed on 02/19/2026 11:47 AM - It Cannot Be Edited


Created By: Kevin Gould On 02/19/2026 at 10:17 AM
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: SACRAMENTO SENIOR LIVING
FACILITY NUMBER: 342701230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2026
Section Cited
CCR
87303(b)(1)

1
2
3
4
5
6
7
Maintenance and Operation: The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).This requirement was not met as evidenced by LPA observations of thermostat in the facility and personal thermometer carried by LPA. LPA observed
1
2
3
4
5
6
7
Licensee shall contact HVAC repair and provide LPA with an estimated repair date. Licensee shall also provide a written statement indicating the steps facility will take to ensure rooms are heated until all repairs are completed.
8
9
10
11
12
13
14
the temperature in the living room, kitchen, and one resident room to be 66 degrees, LPAs thermometer reads 63 degrees. LPA observed this heater not to be working. LPA also observed on the other thermostat, the heat was set to below 68 degrees which poses an immeadiate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
02/20/2026
Section Cited
CCR87309(a)

1
2
3
4
5
6
7
Storage Space and Access: Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are
1
2
3
4
5
6
7
Licensee shall submit a written plan of correction indicating the steps facility will take to review requirements with staff and to ensure such items are stored in a central location secured from residents.
8
9
10
11
12
13
14
 not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of black plastic syringe of insecticide was left on top of the fridge unsecured from residents in care which poses an immediate health, safety and personal rights risk to residents.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/19/2026 11:47 AM - It Cannot Be Edited


Created By: Kevin Gould On 02/19/2026 at 10:46 AM
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: SACRAMENTO SENIOR LIVING
FACILITY NUMBER: 342701230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2026
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
Maintenance and Operation: 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 requirement was not met as evidenced by LPA
1
2
3
4
5
6
7
Licensee shall contact hvac repair and provide an estimated repair date by the POC due date. licensee shall also repair the door frame.
8
9
10
11
12
13
14
observations of the heater for part of the home is not working, LPA observed the thermostat set to 83 degrees and a temperature displayed of 66 degrees. LPA also observed a broken door frame missing part of the wood frame which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
02/20/2026
Section Cited
CCR87555(b)(8)

1
2
3
4
5
6
7
General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as
1
2
3
4
5
6
7
Licensee shall provide a written plan of correction with the steps facility will take to ensure all food is of good quality and not expired.
8
9
10
11
12
13
14
evidenced by LPA observations of expired canned goods ranging from 2018 to 2025 which poses an immediate health safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4