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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701686
Report Date: 09/09/2025
Date Signed: 09/09/2025 03:40:30 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
08/19/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250819031608
FACILITY NAME:GOLDEN HERITAGE SENIOR CARE IVFACILITY NUMBER:
342701686
ADMINISTRATOR:BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 667-9761
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aisake JemesaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed to a resident in care.
Staff did not prevent the facility from being malodorous.
Staff are not providing activities for the residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit.

On 8/24/25, LPA Moleski received an incident report from Bigelow which described a resident's (R1's) family member (R1's RP) raising concerns over medication administration. In an interview, R1's placement agent said they had conducted an audit of R1's medications along with R1's RP on 8/17/25 and observed inconsistencies. LPA Moleski conducted an audit of R1's medications on 8/28/25. LPA Moleski observed discrepancies with R1's medications, including a prostate medication. LPA Moleski observed two bottles of the medication, containing 200 capsules total. The bottles were started on 8/16/25. R1 was ordered to take two capsules every evening. LPA Moleski observed 24 doses signed off on their MARs between the start date and the date of the audit, which should have left 176 capsules remaining. LPA Moleski counted out 98 and 75 capsules between the two bottles, for a total of 173 capsules. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
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 5
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
08/19/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250819031608

FACILITY NAME:GOLDEN HERITAGE SENIOR CARE IVFACILITY NUMBER:
342701686
ADMINISTRATOR:BIGELOW, YELENAFACILITY TYPE:
740
ADDRESS:3801 LAKE TERRACE DRTELEPHONE:
(916) 667-9761
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aisake JemesaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
3
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5
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7
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9
Staff does not serve an adequate amount of food to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. LPAs Moleski and Lindstrom observed breakfast and lunch service during this visit. Resident meal portions appeared to be adequate. In interviews, residents (R1-R5) expressed general satisfaction with meal portions. R1 said that if they asked for more food, staff would be able to get them more. R3 said that the portions are "basically" good, but said it depends upon which staff member is on duty. R2, R4, and R5 voiced no concerns with meal portions. The department has determined the following as it relates to the allegation that staff does not serve an adequate amount of food to residents in care. Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held with Bigelow. Bigelow said staff member Aisake Jemesa could sign this report in her absence. Appeal rights copy of this report were left with Jemesa.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
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: 3 of 5
Control Number 27-AS-20250819031608
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 IV
FACILITY NUMBER: 342701686
VISIT DATE: 09/09/2025
NARRATIVE
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 LPA Moleski performed this count in front of a staff member (S1) to ensure accuracy. S1 raised no concerns regarding the accuracy of the count. LPA Moleski performed a similar count for one of R1's painkillers, and observed another discrepancy. LPA Moleski observed a start date of 6/8/25. R1 was ordered to take one tablet daily. R1's centrally stored medication records indicated the medication was started on 6/8/25. LPA Moleski observed 81 doses administered between that date and the date of the audit, which should leave 19 tablets remaining in the bottle. LPA Moleski counted out 20 tablets in the bottle. S1 observed this count as well and similarly did not voice concerns over the methods used or the accuracy of the count. An antidepressant prescribed for R1 did not have a start date recorded, making an audit impossible.

LPA Moleski received an incident report from Bigelow on 8/25/25. According to the incident report, a resident (R2) refused personal care, and "the strong odor associated with the resident's refusal of hygiene care became noticeable in the common areas and was causing discomfort for other resident." The incident report stated that staff continued to "make efforts to support" R2, but no description was provided of efforts to eliminate or reduce the odor. During LPA Moleski's visit on 8/28/25 and on LPA Moleski's visit on 9/9/25, fairly mild incontinence odors were observed to be present in R2's room. In an interview, R1's placement agent said they had smelled strong incontinence odors on multiple occasions. In interviews, R1 and R3 said that they had sometimes smelled odors coming from R2.

LPAs Moleski and Lindstrom spent several hours at this facility during today's visit. LPAs Moleski and Lindstrom observed no activities being offered to residents. LPA Moleski observed no activities being offered during his visit on 8/28/25 either. In interviews, R1's placement agent, as well as R1-R5, said that there are no activities offered to residents. R3 and R5 said there are games at the facility, but they are not used.

The department has determined the following as it relates to the allegations that staff did not administer medication as prescribed to a resident in care, that staff did not prevent the facility from being malodorous, and that staff are not providing activities for the residents in care:

Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87465(a)(4), 87625(b)(3), and 87219(a). An exit interview was held with Bigelow. Bigelow said staff member Aisake Jemesa could sign this report in her absence. Appeal rights and a copy of this report were left with Jemesa.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
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 5
Control Number 27-AS-20250819031608
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 IV
FACILITY NUMBER: 342701686
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2025
Section Cited
CCR
87465(a)(4)
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"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by:
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Licensee agrees to provide a plan regarding staff training by POC due date. After completing trainings, licensee shall provide LPA Moleski with training sign-in sheets.
vincent.moleski@dss.ca.gov
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Based on interviews, observation, and record review, at least one resident's medications were mismanaged, which poses an immediate health, safety, and personal rights risk.
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Type B
09/16/2025
Section Cited
CCR
87625(b)(3)
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"(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: ... (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence." This requirement was not met as evidenced by:
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Licensee agrees to provide a written plan by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews, observation and record review, the facility contained strong incontinence odors on at least one occasion, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
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: 4 of 5
Control Number 27-AS-20250819031608
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 IV
FACILITY NUMBER: 342701686
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2025
Section Cited
CCR
87219(a)
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"(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:" This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with a written plan to implement activities as of POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and observation, activities were not provided to residents in care, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
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: 5 of 5