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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701574
Report Date: 02/26/2026
Date Signed: 02/26/2026 03:25:25 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
01/22/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260122112616
FACILITY NAME:GOLDEN HERITAGE SENIOR CARE IIIFACILITY NUMBER:
342701574
ADMINISTRATOR:ALITI WAQALALAFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 631-0694
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 6DATE:
02/26/2026
UNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Eliesa Qiolele TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff abandoned resident at hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on February 26, 2026, at 2:46 PM to deliver complaint findings, LPA Martinez met with Eliesa Qiolele, and explained the purpose of the visit.

Confidential interviews were conducted with four individuals during the period of January 28, 2026, to February 26, 2026. Based on interviews conducted and records reviewed, it was determined that the facility did follow the required eviction procedures. It was learned the facility did not provide R1 a 30-day eviction notice. In addition, R1 was not allowed to return to the facility after being discharged from the hospital. LPA Martinez observed R1's belongings in the living room common area on January 28, 2026. Moreover, R1's room was occupied by resident 2 (R2).

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
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-20260122112616
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 III
FACILITY NUMBER: 342701574
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2026
Section Cited
CCR
87224(a)
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87224(a): Eviction Procedures: The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidence by:
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Licensee agrees that the Administrator will be trained on eviction procedures and regulation by a third party trainer by POC Date March 19, 2026. Licensee agrees to email training document to LPA Martinez on March 19, 2026, by 5:00 PM.
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based on file review and interviews, the Licensee did not ensure that a 30 day eviction notice was given to R1 prior to evicting them from the facility. This posed a potential health and safety risk to R1.
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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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260122112616
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 III
FACILITY NUMBER: 342701574
VISIT DATE: 02/26/2026
NARRATIVE
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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.

LPA Martinez also conducted a phone interview with the Licensee during today's visit and worked on POC plan with the licensee. The Administrator was not present at the facility during today's visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3