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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701686
Report Date: 02/18/2026
Date Signed: 02/18/2026 11:37:07 AM

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
02/03/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260203093251
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:
02/18/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Facility Staff: Temo RokomatebulaTIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff did not ensure that the resident was assisted with glucose checks.
INVESTIGATION FINDINGS:
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On 2/18/2026 at 8:40 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Temo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is (6) with (1) facility staff present.

Allegation: Staff did not ensure that the resident was assisted with glucose checks
It was alleged that staff did not ensure that a resident was assisted with glucose checks. This investigation consisted of interviews with facility staff, residents, and records review. On 2/10/2026 LPA Hughes conducted a visit to the facility, LPA spoke with the facility administrator who reported that facility staff assist the resident with glucose checks and prepare the residents insulin injections. Interview with facility staff (S2) stated that staff assist with checking the resident glucose checks at various times throughout the day, as the resident is unable to check their own glucose due to medical diagnosis.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
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-20260203093251
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: 02/18/2026
NARRATIVE
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Facility staff (S2) stated that the resident can administer their own injections. Interview with resident (R1) stated that the facility uses a glucometer to assist with glucose checks, resident (R1) stated that they can inject themselves, and that the facility assist with drawing their insulin. LPA reviewed facility records provided for resident (R1) which reported the facilities daily tracking of resident (R1) glucose levels. This was observed not in compliance with Title 22 regulation 87628(a) as the facility did not ensure that resident (R1) was able to independently perform blood glucose monitoring. Due to the residents medical diagnosis R1 was unable to safely conduct self- glucose checks without assistance.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Temo and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
 
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20260203093251
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: 02/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
02/19/2026
Section Cited
CCR
87628(a)
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87628(a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.
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The licensee agrees to remain in compliance with Title 22 regulation 87628 at all times. The licensee agrees to stop accepting and retaining residents whose medical care exceed the facilities scope of care. The licensee agrees to ensure all residents care needs which fall outside of the facilities scope of care...
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This requirement was not met as evidenced by:
The facility did not ensure that resident (R1) was able to independently perform blood glucose monitoring. Due to the residents medical diagnosis R1 was unable to safely conduct self- glucose checks without assistance.
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are referred to appropriate services when necessary. The licensee review RCFE Prohibited Health Conditions and Title 22 regulation 87628 and send LPA Hughes a statement of acknowledgement of review of the policy by 1/6/2025.
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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: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3