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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701152
Report Date: 07/17/2026
Date Signed: 07/17/2026 10:30:37 AM

Unsubstantiated


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 Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20260211143110
FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:STACY SMITHFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 6DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dillon WilliamsTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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1) The facility allowed excluded individuals to work in the facility.
2) Staff are forging resident documents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Golden Legacy Elderly Care II (RCFE) on 7/17/26 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Staff, Dillon Williams and together discussed the investigation details.

Based on files obtained and reviewed during the investigation process, LPA Gould was unable to corroborate the allegation. LPA reviewed 6 resident files. LPA requested and obtained physician reports (LIC 602) for all 6 residents in care (see confidential name list LIC-811 dated 7/17/26). LPA Gould reviewed reports for each resident. Upon review, the department has no concerns for five of the six physician reports are being altered or fraudulent. The files reviewed appear to be completed by the resident’s physician or an appropriately skilled professional that are able to complete the forms per department regulations.

Report Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
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 Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20260211143110

FACILITY NAME:GOLDEN LEGACY ELDERLY CARE IIFACILITY NUMBER:
342701152
ADMINISTRATOR:STACY SMITHFACILITY TYPE:
740
ADDRESS:2710 EASTERN AVETELEPHONE:
(916) 613-0647
CITY:SACRAMENTOSTATE:CAZIP CODE:
95821
CAPACITY:6CENSUS: 6DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dillon WilliamsTIME COMPLETED:
11:00 AM
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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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Golden Legacy Elderly Care II (RCFE) on 7/1/7/26 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Dillon Williams and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process and LPA observations, the allegations are substantiated. LPA Gould has conducted 14 separate complaint investigations or inspections at the facility since February 2026. Of the 14 inspections/investigations, the Administrator was only able to meet LPA at the facility on two occasions. The department has determined the known administrator was not present at the facility for a sufficient amount of time to provide oversight of facility operations and effectively manage the facility. The facility had no designee with the appropriate experience to properly oversee the facility in the administrator absence and provide oversight to staff providing care and supervision to residents in care. Report Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
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-20260211143110
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 II
FACILITY NUMBER: 342701152
VISIT DATE: 07/17/2026
NARRATIVE
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Additionally, LPA conducted interviews with Three staff members and three residents, all individuals interviewed denied ever witnessing the identified excluded individuals present at the facility. LPA showed pictures of identified excluded individuals and all persons interviewed did not recognize them.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260211143110
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 II
FACILITY NUMBER: 342701152
VISIT DATE: 07/17/2026
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of other is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260211143110
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 II
FACILITY NUMBER: 342701152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2026
Section Cited
CCR
87405(a)
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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and
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licensee shall to provide an updated LIC 500 form indicating the dates and times the administrator are to be at the facility. Additionally, facility will keep a monthly log of administrator presence at the facility including signing in when the administrator arrives at the facility and time they depart the facility to ensure a record of administrator presence at the facility.
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shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by LPA observations and statements received while conducting 14 inspections since February 2026 to present, the administrator was present two of the 14 inspections which poses an immediate health, safety and personal rights 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.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5