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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 12/04/2025
Date Signed: 12/04/2025 01:10:38 PM

Document Has Been Signed on 12/04/2025 01:10 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:		ISIKELI TUIKENATABUAFACILITY TYPE:
740
ADDRESS:7610 LA MANCHA WAYTELEPHONE:
(564) 200-1736
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 14CENSUS: 13DATE:
12/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Isikeli Tuikenatabua (Tui) TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 12/4/2025, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez conducted an unannounced Case Management -Deficiency visit to the facility. LPAs met with facility administrator Isikeli Tuikenatabua (S2) and explained the purpose of the visit.

Interview statements from two staff (S1 and S2), it was learned that unassociated individuals. On two separate accounts LPAs were informed two unassociated individuals were present at the facility.

It was reported P1 and P2 were present at the facility the on or around 9/23/25 and 12/4/25. It was discovered that P1 is the former administrator/licensee at facilities 342700499 342700440 and 342700730, which were closed as of July 2025.Upon guardian and LIS roster review, it was observed that P1 and P2 are on probation and not associated to Legacy Lane Senior Living. A civil penalty applies for having individuals who are excluded and/or not associated to the facility.

During site visit on 12/4/25 around 9:00 AM,LPA Martinez observed P2 and two other unassociated individuals were present outside of the facility. It was confirmed P2 was present in the facility on 12/4/25 and LPAs were informed by facility staff that P2 is at the facility approximately once per week to assist with maintenance work, and they are also called to order supplies and materials needs at the facility. S2 stated R1 called them on 9/23/25, stating “something happened”. S2 stated they were not working at the facility on the week of 9/20/25 due to working at another facility (Vita Bella Elderly Care) and that is why S2 called P1, in order to ask them to come to the Legacy Lane Senior Living in order to have a female speak with R1.

S2 stated there was no other administrator or designated responsible person on site, only care staff, so they called P1, whom is their former employer to come to Legacy lane in order to assist with speaking to R1.

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: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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: 12/04/2025
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 LPA Martinez spoke with S1 over the phone at around 10:35 AM and S1 confirmed they are in New York and have been out of the facility since May 2025 and will return "soon". They will contact LPA Martinez back with a return date. Licensee stated they understood an informal office meeting will be scheduled.

Moreover, LPAs provided guidance on the following: Reporting requests for missed medications and advised staff to maintain an accurate refusal log, and update resident Re-appraisal if the last one was done over 12 months ago or there was a change of condition, whichever occurs first.

A civil penalty shall be assessed on December 04, 2025 , in the amount of $200.00 due to background clearance violations (Criminal Record Clearance 87355(e)(2)). Refer to LIC 421BG form for additional information.



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 421BG, 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: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/04/2025 01:10 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 12/04/2025 at 10:38 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: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
87355(e)(2)

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"87355 Criminal Record Clearance
(e) All individuals subject to a criminal record ... (2) Obtain a California clearance or a criminal record exemption as required by the Department or..." This requirement was not met as evidenced by:
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Licensee and admnisitrator stated P1 and P2 will not return to the facility without clearances. By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87355.
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Based on interviews the facility staff did not comply with the section cited above due to unassociated and excluded persons having been present in this facility. This poses an immediate health, safety or personal rights risk to persons in care.

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Type B
12/05/2025
Section Cited
CCR87405(a)

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"87405 Administrator - Qualifications and Duties d) The administrator shall ... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations." This requirement was not met as evidenced by:
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 By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87405.
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Based on interviews, record review, observations, Administrator did not ensure all adults entering gthe facility shall have a criminal record clearance or exemption. P1 and P2 are not associated to the facility nor is there any personnel records for them at the facility.
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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: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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