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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701690
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:11:06 PM

Document Has Been Signed on 07/01/2025 03:11 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:GOLDEN RESIDENCE SENIOR CARE IIFACILITY NUMBER:
342701690
ADMINISTRATOR/
DIRECTOR:		KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:5105 VILLAGE WOOD DRTELEPHONE:
(916) 840-5298
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 5DATE:
07/01/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Tevi Kaloulasulasu and Ratumanoa NamusudrokaTIME VISIT/
INSPECTION COMPLETED:
03:36 PM
NARRATIVE
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On July 1, 2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct a Pre-Licensing visit following a change of ownership. Upon arrival, LPA was greeted by the applicant, Tevi Kaloulasulasu, who will also serve as the facility administrator. LPA explained the purpose of the visit and proceeded with a brief interview with the applicant Tevi. The census is five.

The facility has a fire clearance for 6 non-ambulatory residents only. At this time, the facility is not approved to accept or retain any residents who are bedridden, nor does it have an approved hospice waiver. According to applicant Tevi, the facility will have a live-in staff and will continue to provide 24-hour care, seven days a week. LPA conducted a tour of the facility, inspecting both the interior and exterior, common living spaces, resident bedrooms, bathrooms, the kitchen, and other areas intended for resident use were all toured. It was observed that the furniture and furnishings were adequate and in good condition to meet the needs of the residents at this time. The garage was inspected and observed that the laundry is kept in the garage and LPA observed that laundry detergent, bleach, and other cleaning supplies were safely stored and inaccessible to residents. All required postings were visible throughout the facility. Smoke and carbon monoxide detectors were tested and found to be in good working condition. A fire extinguisher, located in the kitchen and was observed to be serviced and valid until 11/27/2025. LPA toured all five resident bedrooms, as well as one caregiver room. All furniture and furnishings appeared to be in good repair. During the bathroom inspections, hot water temperatures were taken and the hot water temperature measured 116.1 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit.

Continued LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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: GOLDEN RESIDENCE SENIOR CARE II
FACILITY NUMBER: 342701690
VISIT DATE: 07/01/2025
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In the kitchen, LPA observed an adequate supply of food at least two days’ worth of perishable and seven days’ worth of non-perishable items sufficient to meet the residents’ needs. Kitchen knives were securely locked and inaccessible to residents. The facility’s internal temperature was observed to be 76 degrees, and a public telephone was available in the kitchen for residents’ use. The linen closet, located in the hallway, contained sufficient supplies of clean towels, blankets, and bed linens. Medications were stored in a locked centralized cabinet located in the front entry closet. Together with the applicant Tevi and caregiver Ratumanoa, the resident’s medications with the medication logs were reviewed, which were found to be complete and accurate. File reviews were conducted for five residents and one staff member, and it was complete. The first aid kit was present and contained the required items. Outside the facility, the physical plant was in good repair, free from hazards. The perimeter fencing was secure, and all gates were in working condition.

During today’s visit, LPA Lee observed that the interior layout of the facility does align with the submitted and approved facility sketch. LPA Lee also advised that no changes to the interior or exterior of the facility should be made without prior notification and approval from both the department and the fire department. LPA Lee discussed and recommended the Technical Support Program (TSP) to the applicant, Tevi. The applicant expressed interest in being referred to the program. LPA Lee advised that the referral to TSP will be completed.

Based on the observations made during the visit, the applicant has passed the Pre-Licensing component. Component III was also reviewed with the applicant. LPA will notify the Central Application Bureau (CAB) that the Pre-Licensing visit has been completed and passed. An exit interview was conducted, and a copy of the report was provided to the applicant Tevi.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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