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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701682
Report Date: 09/09/2025
Date Signed: 09/09/2025 12:07:20 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
09/03/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250903212434
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:
09/09/2025
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Tevita Kaloulasulasu TIME COMPLETED:
12:18 PM
ALLEGATION(S):
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Unlawful eviction.
Facility staff withheld mail from residents.
INVESTIGATION FINDINGS:
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On 09/09/25, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Bryon Toliver arrived unannounced to this facility to conduct a complaint visit. LPA me and Ombudsman with care staff Sakeasi Busele who then called administrator Tevita Kaloulasulasu. Approximately an hour later, the administrator Kaloulasulasu arrived at the facility. The purpose of this visit is to open and delivered complaint findings for the above allegations. The current census is 6. A brief interview with administrator Kaloulasulasu was conducted to go over the complaint and its findings.

It was alleged that staff unlawfully evicted a resident. The investigation included interviews with facility staff, the complainant, and a review of relevant records. It was learned that Resident 1 (R1) was issued a 30-day eviction notice dated 08/11/2025; however, R1 did not receive the notice until 08/15/2025. The eviction letter cited non-payment as the reason for eviction, stating “nonpayment of the rate for basic services.”

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

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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-20250903212434
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: 09/09/2025
NARRATIVE
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However, the letter did not specify the dates for which payment was missed or provide any concrete evidence supporting the non-payment claim. LPA Lee reviewed R1’s admission agreement, which indicated that the daily rate for basic services was $202.07 per day. During an interview, Administrator Kaloulasulasu stated that R1 pays $4,500 per month, an amount inconsistent with the admission agreement’s daily rate of $202.07 per day. Additionally, the administrator was unaware of the identity of the third party covering the difference in R1’s rent. Furthermore, the eviction notice did not have several required documents, including a copy of R1’s current service plan, the relocation evaluation, a list of referral agencies, and information regarding the resident’s right to contact the department to challenge the eviction. It also omitted contact details for the local long-term care ombudsman, such as the address and telephone number. Based on the interviews and record review conducted during the investigation, LPA was able to corroborated the allegation that staff unlawfully evicted the resident.

It was alleged that facility staff withheld mail from residents. The investigation included interviews with staff and residents, records review as well as direct observation. LPA Lee interviewed 4 of the 6 residents who expressed concerns about mail being withheld; all four resident stated they were not receiving their mail from facility staff. During the visit, LPA Lee observed that the printer desk drawer was filled with residents’ mail. Upon review, some of the mail belonged to former residents who had moved out prior to the change in ownership. However, it was also observed that (R1)'s mail was among the undelivered items in the drawer. Additionally, Resident 2 (R2), who moved out in mid-August 2025, had 12 unopened pieces of mail stored in the same drawer. Based on the interviews and observations conducted during the investigation, LPA Lee was able to corroborated the allegation that staff withheld mail from residents.

As a result, the allegations are 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 administrator Kaloulasulasu and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250903212434
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: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87224(d)
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87224(d) Eviction Procedures
(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
This requirement was not met as evidence by:
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The administrator agrees to review the eviction regulations by POC date 09/26/2025. The administrator agrees to provide a written statement to LPA that states the review of eviction regulations has been completed by POC
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Based on record review, R1 was served an unlawful eviction notice, which poses a potential health, safety, and/or personal rights risk.
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Date 09/19/2025 end of day 5:00 PM. The administrator also stated that he will revise the eviction letter and reissued it to R1.
Type B
09/26/2025
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities…
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications…
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The administrator agrees to review the regulation cited and provide POC date 09/26/2025. The administrator agrees to provide a written statement to LPA that states the review of eviction
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This requirement was not met as evidence by:
Based on interviews, observation and record review, residents are not given their mails, which poses a potential health, safety, and/or personal rights risk.
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regulations has been completed by POC Date 09/26/2025 end of day 5:00 PM. The administrator also stated that he will have a meeting with the residents in care and facility staff regarding ensuring residents’ mail are delivered to residents accordingly.
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: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3