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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701175
Report Date: 07/02/2026
Date Signed: 07/02/2026 02:21:13 PM

Document Has Been Signed on 07/02/2026 02:21 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 CARE IIIFACILITY NUMBER:
342701175
ADMINISTRATOR/
DIRECTOR:		TAYLOR, MARIEFACILITY TYPE:
740
ADDRESS:7695 RIVER VILLAGE DRTELEPHONE:
(916) 400-4098
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
07/02/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gloria Clarke-Daley and Diana GarciaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Avelina Martinez and Sulma Lopez arrived at this facility unannounced on July 02, 2026, at 10:11 AM to conduct a case management visit. LPAs met with Gloria Clarke-Daley and Diana Garcia and explained the purpose of the visit.

The purpose of the visit today, is in response to the following learned deficiencies: Reappraisals,
It was learned that R1 last Reappraisal/Needs and Service Plan was on May 13, 2025. Resident 6 (R6) last Reappraisal/Needs and Service Plan was on June 24, 2025.

Resident 3's (R3) LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (LIC602) is not complete. Section V. Licensed Medical Professional information is missing information. Resident 4 (R4) LIC 602 Medical Assessment for Residential Care Facilities for the Elderly (LIC602) is not complete. The document has multiple sections that are not completed.

It was also learned that the facility printer is not in good repair. As a result, facility staff are not able to print out July 2026 medication administration records (MAR). There is no record for medication administration as of July 1, 2026. As of 9:30 AM today July 02, 2026, the Administrator has not provided MARs to the facility. The Licensee arrived at the facility approximately 12:37 PM.

Continued...
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2026
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 07/02/2026 02:21 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/02/2026 at 10:14 AM
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 III
FACILITY NUMBER: 342701175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2026
Section Cited
CCR
87463(a)

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87463(a) Reappraisals: the pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition...This requirement was not met as evidence by:
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Facility staff agrees to complete reappraisal audits and complete outdated reappraisals by POC date 7/16/2026. Facility staff shall email completed reappraisals to LPA Martinez by POC date 7/16/2026 at 5PM.
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Based on observation and file review, the Licensee did not ensure that a reappraisal was conducted for R1.
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Type B
07/16/2026
Section Cited
CCR87506(14)

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87506(14) Resident Records: Each resident’s record shall contain at least the following information: Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.
This requirement was not met as evidence by: Based on interviews, observations, and
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Facility staff agree to implement a plan to ensure facility staff have access to Centrally stored medication record. providing the facility with a printer that is in good repair by POC date, 07/16/2026. Facility staff agrees to email stored medication record plan and
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file reviews, the Licensee did not ensure to have a current Centrally Stored medication record. This posed a potential health and safety risk to residents in care.
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updated information on printer status by poc date 07/16/2026 by 5PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2026 02:21 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/02/2026 at 01:02 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 III
FACILITY NUMBER: 342701175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2026
Section Cited
CCR
87506(a)

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87506(a) Resident Records- The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This requirement was not met as evidenced by; based on observation, file reviews, and interviews,
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Facility staff agrees to conduct a resident file audit and ensure that all required documents are maintained, complete, and updated by POC date 7/16/2026. Facility staff agrees to email LPA Martinez audit documentation by POC date 7/16/2026 by 5PM.
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the licensee did not ensure that documents were current, maintained, and complete. This posed a potential health and safety risk to the residents in care.
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Type B
07/16/2026
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
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Facility staff agrees to conduct a medication audit by a medical professional by POC date 7/16/2026. Audit documentation shall be emailed to LPA Martinez by POC date 7/16/2026 by 5PM.
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based on interviews, file review, and observations, the licensee did not ensure that residents were administered their medications as needed. 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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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 LEGACY ELDERLY CARE III
FACILITY NUMBER: 342701175
VISIT DATE: 07/02/2026
NARRATIVE
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LPA Lopez conducted a medication audit and based on the audit findings, the facility did not have the following medications for Resident 3 (R3): diphenhydramine 25mg, Guaifenesin 100mg/15ml. Additionally, R3's prescription medication Senna 8.6mg was not included in the MAR entry.

Resident 5 (R5) did not have the following medications in the facility: Chlorhexidine 0.12% Solution, and Docusate Sodium 250mg. It was learned that these medications ran out yesterday and refills were requested yesterday. This resulted in R5 missing their morning dosages.

Resident 6's (R6) MAR did not reflect the following medications: Senna 8.6mg and Milk of Magnesia 400mg/5m.

It was learned by S1 that the facility printer is in disrepair. Medication Administration Records (MAR) for the month of July have not been printed.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The deficiencies were cited on 809-D
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC809 (FAS) - (06/04)
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