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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701682
Report Date: 07/31/2025
Date Signed: 07/31/2025 01:27:04 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
07/30/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250730162729
FACILITY NAME:GOLDEN RESIDENCE SENIOR CAREFACILITY NUMBER:
342701682
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:27 TRISTAN CIRTELEPHONE:
(916) 619-8590
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Ratusione Nawavoli and Tevita KaloulasulasuTIME COMPLETED:
01:36 PM
ALLEGATION(S):
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Facility alarm is disturbing residents sleep.
Facility does not have hot running water for showers.


INVESTIGATION FINDINGS:
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On July 31, 2025, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to initiate and conclude the investigation into the complaint allegations noted above. Upon arrival, LPA Lee met with direct care staff Ratusione Nawavoli and explained the purpose of the visit. LPA Lee requested that Ratusione contact the facility's designated administrator (FDA), Tevita Kaloulasulasu. A brief phone interview was conducted with FDA Kaloulasulasu, who arrived at the facility approximately 30 minutes later to participate in the visit. The facility census was six residents with 1 staff member present.

It was alleged that facility alarm was disturbing residents’ sleep. The investigation included observations and interviews with staff and residents. During today’s facility visit, it was observed that the fire alarm in resident room #6 had been detached from the ceiling due to continuous beeping.

CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 3
Control Number 27-AS-20250730162729
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 RESIDENCE SENIOR CARE
FACILITY NUMBER: 342701682
VISIT DATE: 07/31/2025
NARRATIVE
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Interviews with both 2 out of 2 facility staff revealed that the fire alarm in room #6 had been beeping since July 28, 2025, typically around 2:00 AM and 4:00 AM, and continued throughout the day. Staff confirmed that the alarm was removed by a resident in room #6 from the ceiling because of the nonstop beeping. Facility Designated Administrator (FDA) Tevita Kaloulasulasu acknowledged that staff informed him of the issue on the same day it began (07/28/2025). He stated that he visited the facility, observed the alarm, and heard it beeping, but had not yet resolved the problem. FDA Kaloulasulasu indicated that a maintenance worker is scheduled to come to the facility today to address the issue. Additionally, interviews with 4 out of 4 residents confirmed that the fire alarm beeps regularly throughout the day and that residents are not able to sleep because staff have not resolved the problem. This was found to be out of compliance with Title 22, Regulation 87468.1(a)(3) Personal Rights of Residents in All Facilities. The facility was not observed to be free from interference with residents' daily living functions, such as sleeping. Based on observations and statements gathered during the investigation, the LPA was able to corroborate the allegation.

It was alleged that the facility does not have hot running water for showers. The investigation included observations and interviews with staff and residents. During today’s facility visit, LPA Lee, along with direct care staff Ratusione Nawavoli, tested the hot water in resident bathroom #1, located on the right side of the facility. The hot water was found to be functional and measured at 118.0°F. However, during interviews, 2 out of 2 facility staff admitted that the hot water had not been working prior to LPA Lee’s visit. Staff member S1 stated that approximately three weeks ago, the hot water in shower #1 (on the right side of the facility) was not functioning. Despite attempts to adjust the shower knob, only cold water was dispensed. As a result, S1 redirected residents to use shower #2, located on the left side of the facility, which is typically designated for staff use. S1 reported the issue to FDA Kaloulasulasu. In an interview with FDA Kaloulasulasu, it was confirmed that he had been informed of the problem by S1 but did not personally check the shower to verify whether it was working or dispensing hot water. This was found to be out of compliance with Title 22, Regulation 87303(e)(2) Maintenance and Operation. Facility faucets used by residents for personal care, such as showering, shall deliver hot water. Based on observations and statements gathered during the investigation, LPA was able to corroborate the allegation.

Due to this investigation, the Department finds the 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. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with direct care staff Ratusione and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20250730162729
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 RESIDENCE SENIOR CARE
FACILITY NUMBER: 342701682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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During today’s visit, administrator Tevita Kaloulasulasu had the facility maintenance guy replace the fire alarm battery to fix the beeping and re-atached the fire alarm back on the ceiling.
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This was not met as evidenced by:

Based on observations and interviews with facility staff and residents in care, the facility did not ensure staff that the fire alarm in resident’s room was in good repair which kept beeping and causing resident to not be able to sleep. This posed an immediate health and safety risk to residents in care.
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The Administrator agreed to conduct training for all staff on residents’ personal rights in all facilities. Additionally, the Administrator will review the cited regulation and submit a signed letter of acknowledgment to LPA Lee confirming that the regulation has been read and understood. The Administrator will also provide LPA Lee with the following by the Plan of Correction (POC) due date of August 7, 2025, by 5:00 PM: Proof of the training conducted, training materials used and staff sign-in sheet
Type A
08/07/2025
Section Cited
CCR
87303(e)(2)
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87303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water...
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During today’s visit, direct care staff Ratusione Nawavoli was able to adjust the shower knob and restore hot water in the shower. The Administrator agreed to conduct training in Maintenance and operation. Additionally, the Administrator will review the cited regulation
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This was not met as evidenced by:

Based on observations and interviews with facility staff and residents in care, the facility did not ensure that the shower in the resident bathroom is delivering hot water for showers. This posed an immediate health and safety risk to residents in care.
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and submit a signed letter of acknowledgment to LPA Lee confirming that the regulation has been read and understood. The Administrator will also provide LPA Lee with the following by the Plan of Correction (POC) due date of August 7, 2025, by 5:00 PM: Proof of the training conducted, training materials used and staff sign-in sheet. The administrator will also conduct a hot water temperature check in the resident shower and provide LPA Lee with the shower log by POC date as well.
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: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3