342701618-3-27-2026-27-AS-CTAO-DSL2SX-20260327173952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701618
Report Date: 03/27/2026
Date Signed: 03/27/2026 05:40:17 PM

Document Has Been Signed on 03/27/2026 05:40 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:	SACRAMENTO SENIOR LIVING III		FACILITY NUMBER:	342701618
ADMINISTRATOR/ DIRECTOR:	SALOTE S LEWIS		FACILITY TYPE:	740
ADDRESS:	8901 SONOMA VALLEY WAY		TELEPHONE:	(530) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 5	DATE:	03/27/2026
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Salote Lewis		TIME VISIT/ INSPECTION COMPLETED:	01:55 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	An informal meeting was held on 3/27/2026 at 1:00PM, at the Sacramento Regional Office via Microsoft Teams. The purpose of this meeting was to discuss concerns regarding licensed facility Sacramento Senior Living III . Participants in the meeting included: Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA), Cynthia Tamyo, and Licensee/ Administrator Salote Charlotte Lewis. During the meeting, the informal conference process, including the administrative process, was explained to the licensee. The current areas of concern were identified as follows: • Administrator Qualifications • Pre-admission appraisals • Reappraisals • Reporting Requirements • Daily Dietary Needs • Planned Activities • Staff Training • Incidental Medical and Dental-proper storage of medications/insulin • Staff Requirements- sufficient in numbers to meet residents’ needs. • TSP services S1 stated they are Licensee and Administrator for three facilities, Sacramento Senior Living II and Sacramento Senior Living III, and Sacramento Senior Living. Licensee stated the facilities are about 15 minutes away from each other and have looked for a new administrator since last year. Licensee stated that as of 3/25/26, they decided to hire two new qualified Administrators for Sacramento Senior Living II and Sacramento Senior Living III. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 III	FACILITY NUMBER: 342701618
	VISIT DATE: 03/27/2026

NARRATIVE

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Licensee informed the Department they plan to remain as Administrator for Sacramento Senior Living. Licensee stated the new Administrators will be present at each facility for 40 hours per week, 8:00AM-5:00PM, Monday – Friday and on-call on weekends. Licensee will submit Administrator change request packet. Licensee also stated they have started to conduct weekly audits for Sacramento Senior Living III by visiting the facilities in person.

Licensee confirmed TSP was received back in September 2025, which they found helpful but would have preferred if services were provided in person at the Facility. Licensee stated an new initial TSP meeting was held two weeks ago, and a follow up meeting is scheduled for April 9th, 2026. Licensee stated they are going to reach out to TSP to request in-person TSP services instead of having virtual meetings. Licensee stated that they want their new Administrators to be present for all future TSP meetings as well.

When asked how they would provide care for R1, who needs a higher level of care, Licensee stated they have a friend who is an Registered Nurse (RN) and they will start to schedule for them to go to the facility “twice per week” to check on the resident’s condition. Licensee also stated they want to ensure their staff are trained to handle emergencies and changes in resident conditions, including reporting any change in condition directly to the Doctor/Physician.

Licensee they will be asking their RN friend to also provide training for staff regarding medications including insulin administration in addition to coming into the facility to check on the R1. Licensee stated they want to ensure R1’s disability is accommodated by seeking out resources from the resident’s advocate.
Licensee stated they will ensure incident reports sent to the Department are detailed moving forwards; Guidance provided regarding reporting requirements include the need to include dates, times, names, timeline, backgrounds, steps and a follow up report will be provided when necessary.
Licensee stated that planned Activities will be discussed with the new Administrator to ensure activities are being provided for residents.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 III	FACILITY NUMBER: 342701618
	VISIT DATE: 03/27/2026

NARRATIVE

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The facilities will do the following to achieve compliance:
• Review regulation for incident reporting
• Train facility staff with training regarding Reporting Requirements
• Increase Administrator oversight; Hire new Administrator for Sacramento Senior Living III
• Review Technical Assistance Program (TSP) resources and request additional assistance when needed.
• Disability Accommodation and Personal Rights training for all staff, licensee will retrain facility staff on proper handling, supervision, support, and meeting residents’ needs without infringing on personal rights.
The facilities will provide the following documentation to the regional office:
• Licensee will submit an updated LIC 500/ LIC 308 for both facilities by 3/30/26.
• Submit Administrator change request for new Administrator(s) by 4/3/26.
• Staff training in Diabetes, Medication, Special Dietary Meals, and Resident Care and Supervision identifying change in condition, and emergency response for all current staff.
• Training in Disability Accommodations and Personal Rights training for residents with disabilities from a disability informed professional.
• Ensure Reappraisals are completed every 12 months or whenever there is a change in condition, whichever occurs sooner.

The regional office will do the following:
• Continue to collaborate and provide assistance to licensee as needed
• Offer TSP services
A link to a list of approved CEU Vendors from the CDSS website was provided to the licensee to research and find vendor-based training for their facilities:https://www.cdss.ca.gov/inforesources/community-care/administrator-certification/administrator-information/list-of-approved-vendors

Per California Code of Regulations (CCR) - Title 22 - no deficiencies are being cited. An exit interview was held, and a copy of the report was sent via email.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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