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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701003
Report Date: 07/07/2026
Date Signed: 07/07/2026 02:12:43 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
02/11/2026 and conducted by Evaluator Sulma Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260211142756
FACILITY NAME:GOLDEN LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR:STACY A SMITHFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 6DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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On July 7, 2026, at 1:30 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived unannounced at the facility to deliver complaint findings for the above allegations. LPAs met with Torika Cowa and Diana Garcia and explained the purpose of the visit.

During this investigation, LPAs conducted interviews, file reviews, and facility inspections. Based on file reviews, it was learned that the administrator was present during 1 out of 5 facility inspection visits. Per the Licesnsee, the facility currently does not have an appointed Administrator resulting in significant lack of oversight on medication administration and the maintenance of facility records.

LPAs observed the following concerns: medication refill supply is being stored with expired medication, not maintaining medication records (MAR), staff not refilling medication in a timely manner, and are not storing them properly,and medication destruction not being completed.
Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR 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.
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
02/11/2026 and conducted by Evaluator Sulma Lopez
COMPLAINT CONTROL NUMBER: 27-AS-20260211142756

FACILITY NAME:GOLDEN LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR:STACY A SMITHFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 6DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Diana Garcia and Torika CowaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
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On July 7, 2026, at 1:30 pm, Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived announced at the facility to deliver complaint findings for the above allegations. LPAs met with Torika Cowa and Diana Garcia and explained the purpose of the visit.

During this complaint investigation, LPAs conducted interviews, file reviews, and facility inspections. LPA Martinez interviewed four out six residents. Two residents did not want to be interviewed. Four out of six residents reported that they have not with witnessed excluded individuals working in the facility. Staff 1 reported that they have not witnessed excluded individuals working in the facility.

It was also learned that the administrator updated Resident 2 (R2)'s Physicians's Report for Residential Care Facilities for the Elderly (LIC 602A). The administrator altered Section I Facility Information to reflect their facility's information. LPAs also observed that the administrator completed section IV- Tuberculosis Test Results using information obtained from R1's previous LIC 602A which is to be completed by the resident's physician. Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260211142756
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 LEGACY ELDERLY CARE
FACILITY NUMBER: 342701003
VISIT DATE: 07/07/2026
NARRATIVE
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Per the Licensee they reported they did not attempt misrepresent the authenticity of LIC 602A. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260211142756
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 LEGACY ELDERLY CARE
FACILITY NUMBER: 342701003
VISIT DATE: 07/07/2026
NARRATIVE
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Also, during a medication administration records review, it was learned that R1 missed their daily dose of Dulcolax 5 MG due to S1 not being properly trained on knowing where refill medication supply was being stored.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211142756
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 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
87405(a)
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87405(a) Administrator - Qualifications and Duties:...administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the
management and administration of the facility...This requirement was not met as evidence by:
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The Administrator shall be present in the facility 40 hours per week starting July 07, 2026. LIC 500 Personnel report shall be emailed to LPA Martinez by July 21, 2026 by 5:00 PM. Licensee will appoint a new administrator by POC date July 21, 2026.
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 based on observation, interviews, and file reviews, the Licensee did not ensure that the admin was present at the facility a sufficient amount of hours to complete management/administration duties. This posed a potential health and safety risk to 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.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Sulma Lopez
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5