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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:43:35 AM

Document Has Been Signed on 02/13/2025 11:43 AM - 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: 7DATE:
02/13/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Cleopatra Gardier TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 02/13/24 at 8:42 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to
conduct a post-licensing inspection. LPA Lee arrived met with administrator Cleopatra Gardier and explained the purpose of the visit. Administrator assisted with today’s visit.

There are currently seven (7) residents currently living at the facility. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 116.3 Fahrenheit. The temperature inside the facility measured at 75 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements Resident Personal Rights, Evacuation Routes and facility license was all posted as required. LPA reviewed 4 out of 7 resident files and 2 staff files. LPA confirmed that residents’ files have the required documents. However, based on resident record review and observation it was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

As a result of this post-licensing visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 02/13/2025 11:43 AM - It Cannot Be Edited


Created By: Pang Lee On 02/13/2025 at 11:17 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in. It was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee stated she is going to have resident re-assed and will talk to family members and find new placement for resident. Licensee will review the regulation cited and provide LPA Lee a statement of acknowledgement of understanding the regulation cite. POC due to LPA Lee by 02/21/25 end of day 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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