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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 05/12/2026
Date Signed: 05/12/2026 03:53:09 PM

Document Has Been Signed on 05/12/2026 03:53 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:
(916) 701-5097
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 14CENSUS: 9DATE:
05/12/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Isikeli Tuikenatabua TIME VISIT/
INSPECTION COMPLETED:
04:16 PM
NARRATIVE
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On 05/12/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a case management visit for a health and safety inspection. The facility is currently on quarterly monitoring due to non-compliance concerns discussed during an informal Microsoft Teams meeting held on 01/03/2026. Upon arrival, LPA Lee met with designated Administrator Isikeli Tuikenatabua and explained the purpose of the visit. At the time of the visit, the facility census was nine (9) residents, with three (3) staff members present.

LPA Lee and Administrator Tuikenatabua toured the physical plant to ensure the health and safety of residents in care. Areas inspected included, but were not limited to, the kitchen, resident bedrooms, resident bathrooms, living room, dining room, and outdoor areas. LPA Lee observed the facility to be free of odors, and activities such as board games, puzzles, and books were available for residents in the common area. LPA Lee also observed a public telephone located in the common area. The facility thermostat was observed at 73 degrees Fahrenheit, which is within the required regulatory range of 68 to 85 degrees Fahrenheit.

During the inspection, LPA Lee observed toxins stored in a kitchen cabinet and in the garage. It was learned that toxins and sharp knives located in the garage were not secured in a locked cabinet or container. Administrator Tuikenatabua stated that the toxins and sharp knives did not need to be separately secured because residents do not have access to the garage and the garage itself remains locked.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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 9
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 9
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: 05/12/2026
NARRATIVE
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 However, during the visit, LPA Lee observed Administrator Tuikenatabua and two care staff entering and exiting the garage multiple times without securing the garage door, making the toxins and sharp knives accessible to residents in care. LPA Lee advised Administrator Tuikenatabua that if the facility chooses to continue storing toxins and sharp knives in the garage, the garage must remain locked at all times and be immediately resecured each time staff enter or exit the area. Alternatively, the facility may install a locked and secured cabinet within the garage to store toxins and sharp knives, ensuring the items remain inaccessible to residents even when staff are frequently entering and exiting the garage.

LPA Lee inspected medication storage and observed medications to be locked and inaccessible to residents. Hot water temperature in a resident bathroom sink measured 116.1 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit. LPA Lee inspected the fire extinguisher and observed that it was last serviced on 03/26/2025. LPA Lee informed Administrator Tuikenatabua that fire extinguishers are required to be serviced annually. Based on records reviewed and information provided by Administrator Tuikenatabua, the last fire drill was conducted on 09/01/2025. LPA Lee informed the Administrator that fire drills are required to be conducted every three months. LPA Lee observed that the facility has two refrigerators, one located in the kitchen and one in the garage. Both refrigerators were observed to be dirty and unsanitary. LPA Lee informed Administrator Tuikenatabua and care staff that the refrigerators must be maintained in a clean and sanitary condition. During the visit, one care staff cleaned the kitchen refrigerator.

LPA Lee followed up on the following areas:

• Food Inventory Supplies:
LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that the seven-day nonperishable food supply was being stored in the locked garage. Per Administrator Tuikenatabua, the food was locked due to a previous resident who wanders at night to eat.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: 05/12/2026
NARRATIVE
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• Accountability/Oversight of Licensee and Administrator:
Per the informal meeting held on 01/03/2026, the Administrator agreed to conduct monthly self-assessments and mock inspections to ensure ongoing compliance. However, Administrator Tuikenatabua was unable to provide documentation showing these assessments and inspections were being completed monthly.

• Criminal Record Clearances:
LPA Lee reviewed staff criminal record clearances and verified that all staff and other individuals requiring caregiver background checks were fingerprint cleared and associated to the facility.

• Reporting Requirements:
LPA Lee reviewed the facility’s incident binder and compared it with the Regional Electronic Facility File. Based on records reviewed, there were two incidents in March 2026, with only one reported; three incidents in April 2026, with only one reported; and one incident in May 2026, as of 05/12/2026, which had not been reported.

• Maintenance and Operation:
LPA Lee observed one kitchen cabinet in disrepair. Administrator Tuikenatabua acknowledged awareness of the damaged cabinet and stated that repairs were needed.

• Fire Safety:
During today’s visit, the facility census was nine (9) residents in care.

• Record Keeping:
LPA Lee reviewed five (5) of five (5) resident files and observed them to be complete. LPA Lee also reviewed three staff files and found one file incomplete. At the time of record review Staff 1’s (S1) file did not contain documentation of employee orientation or the required 40 hours of training completed prior to working at the facility. S1’s employment date was 12/01/2025. Approximately two hours later, Licensee Cleopatra Gardiner texted Administrator Tuikenatabua a photograph of S1’s orientation and 40-hour training documentation. Administrator Tuikenatabua did not have in his file the 20 additional hours of continual training for the year 2025.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: 05/12/2026
NARRATIVE
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• Medication Administration:
LPA Lee reviewed medications and medication administration records (MARs) for three residents and found discrepancies involving two residents. Resident 1 (R1) had two creams, Hydrocortisone 2.5% and Clotrimazole 1%, present at the facility; however, only Hydrocortisone 2.5% was listed on the MAR. Administrator Tuikenatabua stated that Clotrimazole 1% had been discontinued, but no documentation supporting the discontinuation was available.

Additionally, LPA Lee observed that R1’s medications for 05/02/2026 remained inside the bubble pack despite being initialed on the MAR as administered. Further review of R1 and R2’s medications revealed that staff were administering medications out of sequence by removing medications from week two of the bubble pack before completion of week one, indicating the facility was not following the bubble pack instructions as prescribed.

• Name Tags:
Per the informal meeting held on 01/03/2026, the Administrator agreed to implement the use of staff name tags. However, during today’s visit, none of the three staff members present were wearing name tags.

• Administrator Oversight:
Per the informal meeting held on 01/03/2026, the Licensee stated they would ensure the Administrator complied with all applicable laws and regulations while employed at the facility. However, LPA Lee observed multiple deficiencies during today’s visit.

As a result of today’s quarterly visit, deficiencies were cited and can be found on the LIC 809D pages. A civil penalty of $500 was issued during today's visit on LIC 421IM. An exit interview was conducted with Administrator Tuikenatabua and copies of the LIC 809, LIC 809D, LIC 421IM and appeal rights were provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/12/2026 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 05/12/2026 at 03:27 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: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2026
Section Cited
CCR
87303(a)

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87303(a) 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.

This requirement was not met as evidence by:
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The Administrator Tuikenatabua agrees to conduct weekly refrigerator check and clean to ensure that the refrigerators are clean at all times. Log starting today 05/12/2026 to the end of the month will be email to LPA Lee by 05/30/3036 end of day 5:00 PM.
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Based on observations two of the facility refrigerators were dirty and unsanitary. A kitchen cabinet was observed broken. This posed a potential health and safety risk to residents in care.
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Type B
05/22/2026
Section Cited
HSC1569.695(c)

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1569.695(c) Emergency Plans
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill…
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Administrator Tuikenatabua agreed to conduct and document fire drills every three (3) months on the facility’s fire drill log. Administrator will conduct a fire drill for the month of May 2026 and continue conducting drills every three (3) months thereafter.
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Based on record review and an interview with Administrator Tuikenatabua, the facility did not ensure quarterly fire drills were conducted, which poses a potential health and safety and/or personal rights risk to persons in care.
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Proof of the completed May fire drill for 2026, along with a statement acknowledging review and understanding of the cited regulation, will be emailed to LPA Lee by 05/22/2026 by the end of the day.
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:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/12/2026 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 05/12/2026 at 03:30 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: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2026
Section Cited
HSC
1569.625(b)(2)

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569.625(b)(2) Staff training; legislative findings; contents

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours…

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training…

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The Administrator Tuikenatabua agrees to ensure that all staff have 20 additional hours of continual training each year. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.


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LPA Lee reviewed five (5) of five (5) resident files and observed them to be complete. LPA Lee also reviewed three staff files and found one file incomplete. At the time of record review Staff 1’s (S1) file did not contain documentation of employee orientation or the required 40 hours of training completed prior to working at the facility. S1’s employment date was 12/01/2025. Approximately two hours later, Licensee Cleopatra Gardiner texted Administrator Tuikenatabua a photograph of S1’s orientation and 40-hour training documentation. Administrator Tuikenatabua did not have in his file the 20 additional hours of continual training for the year 2025. This poses potential health and safety and/or personal rights risk to persons in care.
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Type B
05/22/2026
Section Cited
CCR87211(a)(1)

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87211(a)(1) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…

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Administrator agrees to send LPA Lee LIC 626/incident reports and to review the applicable 22 CCR sections regarding reporting requirements, and to send LPA Lee a signed statement acknowledging these requirements by POC due date 05/22/2026 end of day 5:00 PM.
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LPA Lee reviewed the facility’s incident binder and compared it with the Regional Electronic Facility File. Based on records reviewed, there were two incidents in March 2026, with only one reported; three incidents in April 2026, with only one reported; and one incident in May 2026, as of 05/12/2026, which had not been reported, which poses a potential health and safety and/or personal rights risk to persons in care. This poses potential health and safety and/or personal rights risk to persons 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:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/12/2026 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 05/12/2026 at 03:33 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: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2026
Section Cited
CCR
87203

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7203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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Administrator will get the fire extinguisher serviced no later than tomorrow 05/13/2026 and provide LPA Lee proof of service along with a statement acknowledging and understanding of the cited regulation emailed to LPA Lee by 05/13/2026 by the end of the day.
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LPA Lee inspected the fire extinguisher and observed that it was last serviced on 03/26/2025, which poses an immediate health and safety and/or personal rights risk to persons in care.
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Type A
05/22/2026
Section Cited
CCR87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities
a. Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...
This was not met as evidenced by:
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The Administrator will ensure that pantry will not be locked and a statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

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LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that the seven-day nonperishable food supply was being stored in the locked garage. Per Administrator Tuikenatabua, the food was locked due to a previous resident who wanders at night to eat. This poses an immediate health and safety and/or personal rights risk to persons 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:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/12/2026 03:53 PM - It Cannot Be Edited


Created By: Pang Lee On 05/12/2026 at 03:35 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: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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he Administrator will ensure that physician orders are followed at all times and ensure that the residents of MAR log are current and accurate at all times. In addition, the administrator will ensure that all residents medication is being administered not out of sequence
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LPA Lee reviewed medications and medication administration records (MARs) for three residents and found discrepancies involving two residents. Resident 1 (R1) had two creams, Hydrocortisone 2.5% and Clotrimazole 1%, present at the facility; however, only Hydrocortisone 2.5% was listed on the MAR. Administrator Tuikenatabua stated that Clotrimazole 1% had been discontinued, but no documentation supporting the discontinuation was available. This poses an immediate health and safety and/or personal rights risk to persons in care.
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and following the correct week per the bubble pack instructions. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.
Type A
05/22/2026
Section Cited
CCR87309(a)

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87309(a) Storage Space and Access
(a) 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 not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
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Administrator agrees to put a locked cabinet in the garage to store the chemicals and sharp knives and have it locked at all times. Administrator will email LPA Lee photo of the cabinet with the chemicals and knives by 05/22/2026 end of day 5:00 PM.
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Based on observation, the Administrator did not comply with the section cited above. LPA Lee observed toxins and sharp knives unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons 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:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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