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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701003
Report Date: 07/07/2026
Date Signed: 07/07/2026 02:24:18 PM

Document Has Been Signed on 07/07/2026 02:24 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 LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR/
DIRECTOR:		STACY A SMITHFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY: 6CENSUS: 6DATE:
07/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Diana Garcia and Torika CowaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at this facility unannounced on July 07, 2026, at 1:30 PM to conduct a case management visit. LPAs met with Torika Cowa and Diana Garcia and explained the purpose of the visit.

The purpose of the visit today is in response to the following learned deficiencies: Incidental Medical and Dental Care.

It was learned that the facility is not refilling resident medication in a timely manner, resulting in missed medications. Facility staff are also not maintaining the Medication Administration Record (MAR) accurately. Staff do not initial the MAR indicating that the medication has been administered. Additionally, there are medications present in the facility that are not being documented on the MAR. Medication destruction is not being completed.

Based on this case management inspection, the facility will be cited the following deficiencies Incidental Medical and Dental Care 87465 (a)(6) and 87465 (4). These deficiencies can be found on the 809-D page.
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2026
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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Document Has Been Signed on 07/07/2026 02:24 PM - It Cannot Be Edited


Created By: Sulma Lopez On 07/06/2026 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE
FACILITY NUMBER: 342701003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2026
Section Cited
CCR
87465(a)(6)

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87465(a)(6) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility...When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility
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Facility staff will conduct a medication audit by a medical professional by POC date July 21, 2026. Facility staff agrees to email LPA Martinez a copy of the medication audit report by POC date July 21, 2026 by 5:00pm.
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This requirement was not met as evidenced by based on interviews, observation, and file reviews, the licensee did not ensure that facility staff were maintaining accurate medication administration records. This posed a potential health risk for residents in care.
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Type B
07/21/2026
Section Cited
CCR87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by based on
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Facility staff will conduct a medication audit by a medical professional by POC date July 21, 2026. Facility staff agrees to email LPA Martinez a copy of the medication audit report by POC date July 21, 2026 by 5:00pm.
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interviews, observations, and file review, the licensee did not ensure that facility staff were assisting residents with medication administration as required. This posed a potential health and safety risk for residents in care.
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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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2026 02:24 PM - It Cannot Be Edited


Created By: Sulma Lopez On 07/07/2026 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN LEGACY ELDERLY CARE
FACILITY NUMBER: 342701003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2026
Section Cited
CCR
87465(i)(1-4)

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87465(i)(1-4) Incidental Medical and Dental Care- Prescription medications… which are not returned to the issuing pharmacy… or which are otherwise to be disposed shall be destroyed in the facility by the facility administrator and one other adult who is not a resident...
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Facility staff will conduct an in service medication destruction training by a medical professional by POC date July 21, 2026. Facility staff agrees to email LPA Martinez a copy of the in service training document by POC date July 21, 2026 by 5:00pm.
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This requirement was not met as evidenced by: based on interviews, observation, and file reviews, the licensee did not ensure medications were properly disposed and destructed. This posed a potential health and safety risk for residents in care.
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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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2026


LIC809 (FAS) - (06/04)
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