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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 08/12/2025
Date Signed: 09/22/2025 11:41:30 AM

Document Has Been Signed on 09/22/2025 11:41 AM - 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: 12DATE:
08/12/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Isikeli TuikenatabuaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 8/12/25 Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced POC visit to the facility to verify correction of citations issued on 7/23/2025. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit.

Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. The current census was 12. LPA Tamayo called Administrator at 9:23AM and left a voice message requesting a call back. LPA Tamayo revived a text message from Administrator stating " Sorry, I can't talk right now". LPA has not received any follow up from Administrator since 7/23/25. LPA observed 3 residents eating breakfast at the dining table between 9:00AM- 10:00 AM. At 11:40 AM, LPA observed S3 and S4 starting to prepare lunch.

S2 stated they do not know the return date for Administrator. S2 stated they last spoke to Administrator via phone three days ago to consult regarding the facility. LPA observations and Staff statements confirm there has not been any administrator oversight for several months. LPA Tamayo last saw Administrator on 4/25/25 and has not seen them at the facility since 6/13/25.

Per LIC 500 dated 7/2025 staff/administrator, Moira Ganavou (S5) , is scheduled to work Friday- Sunday 7:00 AM-7:00AM. S5 Administrator certificate expires 6/6/2026, however LIC 308 designates S2 as Responsible for the facility. S2 sated they are in the process of obtaining an Administrator Certificate, they provided verification of 80 hours of training, completed between 5/1/25-5/18/2025. S2 provided LPA with a written statement from administrator stating S2 has completed Administrator training and will be assigned as administrator once they obtain their pending certificate (6078436740).

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: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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: 08/12/2025
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LPA did not observe S2 on the list of “Active Administrator Certificate Holders” during this visit. A Civil Penalty for failure correct for POC regarding administrator oversight.

S2 states groceries are ordered and delivered via the Walmart Mobile applications. Groceries are delivered twice a week. S2 stated Administrator also places orders on their end if anything is ever needed for the facility. LPA observed enough food for 12 residents in care in the refrigerator.

S2 stated two incident report (SIRs) were faxed into CCL RO on 8/8/25 and 8/9/25. LPA Tamayo did not observe any Incident reports that came in from the facility in the last month. S2 provided successful fax confirmation verification. LPA will add the SIRs to the facility file. S1 agreed to send in future SIR’s the Regional Office email to ensure timely reporting.

LPA reviewed staff file for Donnovan Jr Williams, (S6). S6 is background cleared but is not associated to the correct facility (facility Legacy Senior Living, 342701230). S2 notified the Administrator and they remotely associated S6 to the facility via Guardian during this visit.

LPA measured the hot water temperature in the kitchen faucet, hot water temperature was 105.3 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. POC for hot water temperature cleared. S2 provided LPA with POC verification was received confirming Staff completed training on storing of toxins, cleaning supply was completed on 7/25/25. POC for storage of toxins has been cleared. S2 stated Dementia Training for all staff was completed on 8/8/25. Upon record review, LPA observed an LIC 621 was updated for each resident.

LPA requested the following documents to be submitted by 5:00PM on 8/13/2025:
LIC 500 for May-August 2025

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: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 08/12/2025
NARRATIVE
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 Licensee complied with the terms of the POC by POC due date for two out of three deficiencies cited under Title 22 Regulations on 7/23/25 and have been cleared. Original POC for administrator oversight dated 6/30/25, a CP was issued on 7/23/25 for Failure to Correct. Another Civil Penalty (CP) for failure to correct is applied due to outstanding plan of correction regarding administrator oversight.

As a result of this POC visit one (1) deficiency was cited (See LIC809D). An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, Civil Penalty, POC clearance letters, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2025 11:41 AM - It Cannot Be Edited


Created By: Cynthia Tamayo On 08/12/2025 at 12:08 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: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2025
Section Cited
CCR
87405(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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Original POC dated 6/30/25 was not completed by POC due date. CP was issued on 7/23/25 for Failure to Correct. Another CP was issued 8/12/25 for failure to correct. Facility will designate a qualified administrator to facility at all times by POC due date.
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This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, 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: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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