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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:15:58 PM

Document Has Been Signed on 03/13/2025 12:15 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: 10DATE:
03/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Cleopatra GardinerTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 3/13/25 at 11:00am Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced Case Management Deficiencies inspection to address deficiencies observed during another complaint inspection.

LPAs conducted a walk through of the facility and LPAs observed a resident's insulin medication in a refrigerator located in the garage stored with resident food and and not secured from other resident access. LPA observed the door to the closet only has dead bolt lock which can be opened by any resident, LPA inquired if facility has a key to lock the lower handle and Licensee did not have access to a key to lock the garage door and make inaccessible to residents in care. LPA observed a lock box provided to the facility and maintenance was on site to address locking doors.

Per California Code of Regulations, Title 22 the following deficiency is cited.

Exit Interview conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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Document Has Been Signed on 03/13/2025 12:15 PM - It Cannot Be Edited


Created By: Kevin Gould On 03/13/2025 at 11:53 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: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2025
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not
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LPA observed a lock back be delivered to the facility. LPA will clear deficiency.
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met as evidenced by, LPAs observations of insulin medication being stored in a fridge in the garage that was not made inacessible to residents in care wich poses an immediate health, safety or personal rights risk to residents in care.
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CCR

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CCR


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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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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