<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 09/29/2025
Date Signed: 09/29/2025 07:19:33 PM

Document Has Been Signed on 09/29/2025 07:19 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: 13DATE:
09/29/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Isikeli TuikenatabuaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/29/2025, Licensing Program Analyst (LPA) Cynthia Tamayo and Licensing Program Manager (LPM) Czarrina Camilon-Lee conducted an unannounced Case Management POC visit to the facility to verify correction of citations issued on 8/12/LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Current administrator/Licensee (S1), Cleopatra Gardiner was not present at the facility. S2 called S1. Administrator, Cleopatra Gardiner, was contacted via phone call and informed she will return to the facility next Monday, 10/6/25. S1 stated that S2 will be instated as administrator, and agreed to send request for change of administrator on this day.

LPA and LPM met with Direct care staff, Isikeli (S2) Tuikenatabua. The census is 13.
LPM spoke with staff regarding ensuring all exits are and staff supervision requirements.

Staff 3 (S3), LPA Tamayo, and LPM Camilon-Lee went on a tour of the facility.
LPA and LPM observed the garage door was unlocked and there were cleaning supplies and toxins including laundry detergent and medications in the entrance area of the garage, accessible to residents. A deficiency and civil penalty for repeat violation was applied. LPA observed S2 lock garage door immediately.

LPM observed staff preparing lunch was frozen corn dogs and pizza. LPA did not observe any snacks to be distributed. LPA/LPM observed the smoke detectors went off when staff where preparing lunch. LPA Tamayo observed the exhaust fan is not working. LPA observed staff preparing dinner around 4:30 PM which included frozen chicken strips, frozen French-fried that were prepared in the oven, and watermelon and melon mix. LPA observed a lock mechanism in a kitchen drawer, S2 stated they used to lock the refrigerator but do not practice doing so any longer.
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: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
Document Has Been Signed on 09/29/2025 07:19 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 09/29/2025 at 10:36 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: LEGACY LANE SENIOR LIVING
FACILITY NUMBER: 342701414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2025
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
87309 Storage Space and Access(a) Except as specified in subsection (b) ... disinfectants, cleaning solutions, poisonous substances ... and other similar items ...are in locked storage and are not left unattended if outside the locked storage.
1
2
3
4
5
6
7
Facility has agreed to lock disinfectants, cleaning solutions, poisonous substances, and medications etc. located in the garage and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.
8
9
10
11
12
13
14
 This requirement was not met as evidenced by LPA observations of cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
10/10/2025
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
Licensee will have exhaust fan repaired by POC due date. Licensee will send maintenece work order/invoice to LPA Tamayo at cynthia.tamayo@dss.ca.gov by POC due date.
8
9
10
11
12
13
14
this requirement was not met as evidenced by LPA observations of kitchen exhaust fan not working properly which poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/29/2025 07:19 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 09/29/2025 at 01:15 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: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2025
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (a) all facilities shall have a qualified and currently certified administrator ...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the
1
2
3
4
5
6
7
Facility must designate a qualified administrator to facility at all times. Licensee will submit an updated LIC 308,provide a statement of review and understanding for 87405(a), and a plan to ensure there is always a qualified Administrator to LPA by POC due date.
8
9
10
11
12
13
14
management and administration of the facility as specified ... When the administrator is not in the facility ... 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...
This requirement was not met as evidenced by facilities not having a qualified administrator, this poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
10/03/2025
Section Cited
CCR87412(a)

1
2
3
4
5
6
7
87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain ...
This requirement was not met as evidenced by facilities not a record available for all working staff
1
2
3
4
5
6
7
Licensee will submit a statement of review and understanding for 87412(a) and a plan to ensure there is always a personnel record for all past and future staff and volunteers effective by POC due date. Licensee will also ensure all on-call/ back up staff are listed on all future LIC 500 Personnel Record forms
8
9
10
11
12
13
14
, this poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2025


LIC809 (FAS) - (06/04)
Page: 4 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: 09/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff 5 (S5) was present and working at the facility on 9/23/25. S5 does not have a staff record for review as required by Title 22 regulations. .

LPA obtained for four residents (R1-R4) records and four staff records .

Licensee failed to correct an outstanding plan of correction regarding administrator oversight. A civil penalty issued for failure to correct deficiency was last cited on 8/13/2025, in which the original deficiency was cited on 6/30/25. S2 emailed LPA their Administrator Certificate during this visit, however, the LIC 308 designates another staff as responsible representative and the complete POC has not been submitted to LPA Tamayo by the Licensee.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, LIC 421FCs, 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: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5