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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701414
Report Date: 06/13/2025
Date Signed: 06/13/2025 10:48:20 AM

Unsubstantiated


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
03/11/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250311084847
FACILITY NAME:LEGACY LANE SENIOR LIVINGFACILITY NUMBER:
342701414
ADMINISTRATOR:GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:7610 LA MANCHA WAYTELEPHONE:
(564) 200-1736
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:14CENSUS: 10DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Isikeli Tuikenatabua TIME COMPLETED:
10:58 AM
ALLEGATION(S):
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1) Staff handled resident roughly.
2) Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Cynthia Tamayo made an unannounced inspection to the Legacy Lane RCFE on 6/13/25 at 8:57 A.M. to conclude the investigation of the above allegations and to deliver the findings. LPA Tamayo met with staff, Isikeli Tuikenatabua and together discussed the purpose of the visit.

This investigation consisted of interviews, observation, and record review. Six residents (R1-R6) and four staff members (S1-S4) were interviewed. LPA Tamayo reviewed six residents' (R1 and R6) files.
According to Rebecca Danenberg’s (R1) admission agreement, dated 2/5/24 R1's LIC 602 diagnosed R1 with Paraplegia and Venous insufficient. Cognitive deficits were identified for R1 include hypertension, anxiety, and PTSD. Substance abuse problem identified on LIC 602 for R1. R1 was identified as non-ambulatory, which means that the resident should be able to turn, rotate, and/or reposition themselves in bed and assistance with dressing is needed.

Report Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
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-20250311084847
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: 06/13/2025
NARRATIVE
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LPA conducted an interview with RP who reported allegations made by R1. LPA interviewed R1 and they stated they requested to be moved and were not given an eviction notice. Methodist Hospital assisted R1 with obtaining a new placement. LPA reviewed resident record for R1.

Five (5) current residents’ interviewed reported that they like the staff and are well cared for. No concerns regarding care were voiced by residents who were interviewed. Current residents interviewed did not voice specific concerns regarding the conduct of S2. S1, S2, S3 stated no staff has handled residents roughly. S1 stated R1 was hospitalized on 3/9/2025 and was relocated to another facility that can better assist her with the adequate care including their need for a special size mattress and Hoyer lift due to R1's weight. Residents and staff interviewed could not verify that this incident occurred as described by R1.

The department has determined the following as it relates to the allegations that staff handled client roughly and unlawful eviction. Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding these allegations. Exit interview was conducted with facility staff. A copy of this report were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
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