342701414-6-9-2026-27-AS-SRIN-DVDNRW-20260625104212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701414
Report Date: 06/09/2026
Date Signed: 06/09/2026 09:47:10 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2026 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20260604100942

FACILITY NAME:	LEGACY LANE SENIOR LIVING		FACILITY NUMBER:	342701414
ADMINISTRATOR:	ISIKELI TUIKENATABUA		FACILITY TYPE:	740
ADDRESS:	7610 LA MANCHA WAY		TELEPHONE:	(916) 701-5097
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	14	CENSUS: 11	DATE:	06/09/2026
		UNANNOUNCED	TIME BEGAN:	07:59 AM
MET WITH:	Pene Henefiro and Merewalesi Qalikaisi		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not notify residents authorized representative of an incident
Staff left resident in soiled clothing
Staff did not ensure resident wore protective helmet
Staff are not communicating with resident's authorized representative regarding appointments
Staff are not managing resident's pain
Staff did not ensure the facility was kept clean
Staff are not meeting resident's hygiene needs

INVESTIGATION FINDINGS:

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On 06/09/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to initiate and conclude a complaint investigation. LPA Lee met with care givers Pene Henefiro and Merewalesi Qalikaisi. The facility census was eleven residents, with two staff members present at the time of the visit. A phone interview was conducted with facility administrator Isikeli Tuikenatabua.

It was alleged that staff did not notify resident's authorized representative of an incident, staff left a resident in soiled clothing, staff did not ensure resident wore a protective helmet, staff are not communicating with the resident's authorized representative regarding appointments, staff are not managing resident's pain, staff did not ensure the facility was kept clean and staff are not meeting resident's hygiene needs. The investigation consisted of record reviews and interviews with Administrator Tuikenatabua and the Reporting Party (RP). Based on a review of the resident roster, it was learned that there are no residents by the name of Resident 1 (R1) residing at the facility.
CONTINUED LIC 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260604100942

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/09/2026

NARRATIVE

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During an interview with Administrator Tuikenatabua who confirmed that there is no resident by the name of R1 who resides at the facility. Additionally, the Reporting Party stated that R1 resides at 9442 Mazatlan Way, Elk Grove. Further review determined that the complaint was filed against the incorrect facility. R1 does not reside at Legacy Lane Senior Living located at 7610 La Mancha Way, Sacramento. Rather, R1 resides at Legacy Lane Senior Living III, located at 9442 Mazatlan Way, Elk Grove. Therefore, the allegations are not associated with the facility identified in this complaint investigation.

The Department has investigated the complaint allegations listed above and determined the complaint to be UNFOUNDED, meaning the allegations were false, could not have happened, and/or was without reasonable basis. Therefore, the complaint has been dismissed. No deficiencies were observed or cited during today’s complaint visit. An exit interview was conducted with care staff Henefiro.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC9099 (FAS) - (06/04)

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