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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701248
Report Date: 05/15/2025
Date Signed: 05/15/2025 02:04:24 PM

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
05/07/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250507142611
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: 5DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Netani Tuivu TIME COMPLETED:
01:46 PM
ALLEGATION(S):
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Facility staff did not properly supervise client resulting in elopement
INVESTIGATION FINDINGS:
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On 05/15/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to open and closed the complaint allegation outlined above. LPA met with caregiver Netani Tuivu to explain the purpose of the visit. A brief interview was conducted with administrator Salote Lewis via telephone call. The census is 5 with 1 facility staff.

It was alleged that facility staff did not properly supervise client resulting in elopement. This investigation included interviews with staffs and records review. In an interview with both administrator Salote Lewis and caregiver Netani Tuivu, both admitted that resident 1 (R1) left the facility unsupervised. Based on records review it was learned that on 04/30/25, R1 left the facility unsupervised and was brought back to the facility by law enforcement. Per R1's LIC 602, Physician Report dated 10/02/23 R1 has a history of wandering behavior and is unable to leave the facility unassisted. Based on the interviews conducted during the investigation process and records review, LPA Lee was able to corroborate the allegation.

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 standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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-20250507142611
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: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2025
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
This was not met as evidenced by:
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Administrator agrees to conduct basic services (to include care and supervision) training for all staff using an approved vender through CCLD. Administrator will read the regulation cited and provide LPA Hughes a letter of acknowledgement that the regulation cited was reviewed and understood.
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Based on records review, and interview with the administrator and care giver the facility did not ensure staff provide care and supervision to R1. Due to not providing care and supervision, R1 left the facility unassisted. This posed an immediate risk to residnets in care.
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Administrator will also put a plan in place for residents who are wonderers to ensure the residents safety. Administrator will email documents used for training and sign in sheet and plans in place for residents who are wonderers by POC Date 05/24/2025 by end of day 5:00pm.
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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: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
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