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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 06/30/2025
Date Signed: 06/30/2025 06:26:29 PM

Document Has Been Signed on 06/30/2025 06:26 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:LEGACY LANE SENIOR LIVINGFACILITY NUMBER:
342701414
ADMINISTRATOR/
DIRECTOR:		GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:7610 LA MANCHA WAYTELEPHONE:
(564) 200-1736
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 14CENSUS: 11DATE:
06/30/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Isikeli Tuikenatabua TIME VISIT/
INSPECTION COMPLETED:
06:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management (CM) Plan of Correction POC follow up visit. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Ombusdman Byron Toiliver was also present during this visit.

Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. Administrator, Cleopatra Gardiner (S1) was not present during this CM POC follow up visit nor was she at the facility during the last case management visit that was conducted on 6/13/25. on 6/13/25,S2 stated S1 was not working that day due to being out sick. On 6/17/25, LPA Tamayo emailed a copy of the 809-D from CM visit that took place 6/13/25. S1 responded back via email on 6/17/25 stating they will submit the POC by the due date of 6/27/25. No POC verification has not been received by the Regional Office as of today, 6/ 30/ 2025 and POC is overdue. A civil penalty for failure to correct applied due to outstanding plan of correction regarding reporting requirements.

Additionally, a posted LIC 500 Personnel Report dated 6/202/25 indicates S1 is scheduled to work Monday thru Wednesday 7:00 AM-7:00 PM. There is no LIC 308 on file or submitted to Community Care Licensing informing the administrator will be out of the facility and who is designated facility responsibility. The return date for the administrator is unknown by staff (S2, S3, S4 ) and residents (R1, R2, R3. During today’s visit S3 stated has been out of the facility on vacation in New York for about one month. Three residents stated they have not seen S1 for a long time for about “2 months” and do not know where S1 is. Initially, S2 stated S1 has been out on vacation for two weeks, but when LPA Tamayo asked why staff (S3) and 3 residents (R8, R4,and R3) say they have not seen S1 for 1- 2 months.
[continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414
VISIT DATE: 06/30/2025
NARRATIVE
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 S2 then stated that S1 has not been at the facility since 1 month and does not know S1’s return date. S2 stated they are “kind of” in charge while S1 is out. S2 called S1 via phone call and they sent over an LIC 308 which designates S2 as responsible. S2 stated they do not have an administrator certificate. LPA Tamayo is concerned for the operation of the facility due to having no/minimal administrator oversight.

LPA measured the water temperature in the two resident bathrooms, temperature measured at 144 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA measured the water temperature in kitchen faucet, temperature measured at 98 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept unlocked and accessible to residents. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept locked and inaccessible to residents. LPA observed S2 lock both cabinets immediately during this visit when asked to do so. As this is a repeat violation, an additional civil penalty of $250 is hereby assessed.

LPA reviewed Resident Records for R1-R8 and observed there were incomplete forms including missing signatures/name, dates, and information for resident forms including consent forms to receive medical treatment and admission agreements.

LPA reviewed Physicians report for residents (R1-R8). R3 is prescribed Morphene (To be administered three times per day). LPA saw there is no Morphene medication left, as the 90 pills were filled on 5/22/25 and were finished on 6/21/2025. However, MARS records show that S2 signed off on Morphene medication being administered to R3 three times a day 6/22/25-6/29/25 and at 8:00AM on 6/30/25. S2 stated they signed/initialed the MARS for R3 Morphene medication was taken but they shouldn’t have from 6/22-6/20/2025.

Additionally, S2 stated they gave R3 their personal over the counter Tylenol on 6/29/25 around noon due to R3 having pain. Tylenol is not listed for R3.

LPA Tamayo was concerned about R3’s medical state and asked R3 if they would like EMS to be contacted. R3 requested immediate medical attention at 3:40 and EMS was immediately contacted by S2. EMS arrived at 3:55PM and transported R3 to the hospital. LPA Tamayo reminded staff an Unusual Incident Report (UIR/SIR) is required for Emergency Transport of residents. S2 gave LPA Tamayo SIR at 4:30PM.
Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 06:26 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 06/30/2025 at 04:58 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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2025
Section Cited
CCR
87309(a)

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Storage Space and Access: except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are
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Facility has agreed to: lock cabinets containing disinfectants, cleaning solutions, poisonous substances, etc. and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.
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 not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
07/07/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management ..
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Facility has agreed to: Communicate with LPA Tamayo to inform CCL of Administrator return date. Assign a qualified certified administrator during Administrator absence.
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This requirement was not met as evidenced by LPA observations of administrator not being in the facilty for over a month with no known return date, this poses a potential 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414
VISIT DATE: 06/30/2025
NARRATIVE
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No Plan of Correction for CM visit dated 6/13/25 has been received, a civil penalty is assessed due to failure to correct.

The follong deficiencies are cited on the corresponding 809-D per California Code of Regulations, TITLE 22. At 6:54 PM and exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 06/30/2025 06:26 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 06/30/2025 at 05:24 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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2025
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital.
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Licensee failed to correct Deficiency cited on 6/13/25 by POC due date on 6/27/25. Licensee agrees to send timley reports and provide verification of review and understanding of regualtion 87211 to LPA Cynthia Tamayo by POC due date at cynthia.tamayo@dss.ca.gov . A Civil Penality is assessed for failure to correct.
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Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.
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Type B
07/07/2025
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)
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Licensee will schedle maintenace to regulate water temperature attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) by POC due date.
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Based on record review and interview, this requirement was not met as evidenced resident bathroom faucet measuing 144 degrees F and kitchen faucet water is measured at 98 degrees F. This poses 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:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 06/30/2025 06:26 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 06/30/2025 at 05:38 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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2025
Section Cited
CCR
87465(e)

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87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...and the label shall contain...information.
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Facility agrees to submit an SIR for medication administration error. Licensee will provide training materials to the department by The POC due date.
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This requirment was not met as evidenced by: Over the counter medication that are not prescribed by resident's doctor was administered to resident on 6/29/25 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 06/30/2025 06:26 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 06/30/2025 at 05:44 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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2025
Section Cited
CCR
87465(e)

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87465 Incidental Medical and Dental Care (c)... facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(3)A record of each dose is maintained in the resident's record... the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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Licensee will submit an SIR to Community care Licenseing for medication administration errors. Licensee will conduct training for all staff members and provide training materials to the department by The POC due date.
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This requirment was not met as evidenced by: Staff signed off that resident received a prescribed medication from 6/22-6/31/5 even though they did not administer medications, as the medication were done by 6/21/25. which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
07/07/2025
Section Cited
CCR87507(c)

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87507 Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative ...no later than seven days following admission...
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Resident records for all residents will be filled out, signed, and dated by POC due date and submitted to LPA Tamayo via email.
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This requirment was not met as evidenced by incomplete resent records 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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