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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701414
Report Date: 12/04/2025
Date Signed: 12/04/2025 01:15:09 PM

Substantiated


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
09/19/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250919152014
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: 13DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Isikeli Tuikenatabua (Tui) TIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff failed to report suspected sexual abuse of a resident
Staff did not ensure that resident's dietary needs are met
INVESTIGATION FINDINGS:
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On 12/4/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez arrived unannounced to conduct a complete and deliver complaint investigation findings into an allegations noted above. LPA met with administrator, Isikeli Tuikenatabua (S2), and stated the purpose of this visit.

LPA requested the following records for review:
• LIC 500
• LIC 9020
• LIC 308

Allegation: Staff failed to report suspected sexual abuse of a resident
It was alleged that Staff failed to report suspected sexual abuse of a resident The investigation into the above allegation consisted of interviews and record reviews.
CONTINUED ON 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20250919152014
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: 12/04/2025
NARRATIVE
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During interviews with two staff (S2 and S5) and two residents (R1 and R2) it was learned that Resident 1 (R1), whom is a dependent adult, reported to S2, P1, S6 and P2, that they had been inappropriately touched by Staff 3 (S3) on 9/23/25. Record review and interviews confirm that S1- S7, P1, and P2 did not complete report the incident timely to community care licensing regional office via unusual/special report, phone call, nor an SOC 341 form. S1-S7 are mandated reporters, however they did not ensure timely reporting requirements were completed when the R1 reported they were inappropriately touched in a sexual manner to staff. Based on interviews and observations of the LPA and review of records the allegation that staff failed to report suspected sexual abuse of a resident, is substantiated. A civil penalty for repeat violation applies.

Allegation: Staff did not ensure that residents’ dietary needs are met
It was alleged that staff did not ensure that residents’ dietary needs are met, this investigation consisted of facility observation, interview with residents in care, and resident records review. On 9/29/2025, LPA Tamayo conducted a visit to the facility and observed 5 residents sitting at the dining room table having lunch and dinner in which they were consuming food items that did not meet their prescribed dietary requirements; it was observed that staff preparing lunch was frozen corn dogs and pizza.R6 has a diagnosis of diabetes and there is no special menu nor alternatives offered for them.

Interview with 2 out 5 residents revealed concerns with food being served. 5 out of 5 residents in the facility stated in between meal snacks are not being provided. LPA did not observe snacks were made available to residents in between meals during multiple visits including 4/25/25,6/13/25,6/30/25,7/23/25,8/12/25, and 9/29/25. Additional review of facility’s Admissions Agreement indicates that residents in care will receive nutritious and well-balanced meals that meet their individual dietary meals requirements. This was observed not in compliance with Title 22 regulation 87555(a). LPAs did not observe any fresh fruit out on the counter available to residents. LPAs observed waffles, oranges, and grapes were given for breakfast and lunch was burgers, chocolate cake, orange, and soda. S2 stated canned soup is available for anyone who wants an alternative.

Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that resident's dietary needs are met, is substantiated.

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20250919152014
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish… (1) A written report ... to the licensing agency and to the person responsible …(D) Any incident which threatens the welfare, safety or health of any resident … this requirements was not met
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 Administrator submitted LIC 624 to LPA Tamayo on 9/29/25. By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87211 Reporting Requirements in addition to a plan to train all staff on mandated reporter requirements.
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 as evidenced by staff not reporting suspected abuse that was reported to them by resident 1(R1) on the week of 9/19/25. Additionally, staff did not complete the required SOC 341 form and failed to complete a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency. This poses an immediate health and safety risk to residents in care.
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 POC can be submitted to cynthia.tamayo@dss.ca.gov.
Type B
12/12/2025
Section Cited
CCR
87555(a)
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 87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirements
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By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87555 General Food Service Requirements in addition to a plan to ensure that resident's dietary needs are met and all foods shall be selected, stored, prepared and served in a safe and healthful manner.
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was not met as evidenced by interview and observations made of
staff not ensuring that resident's dietary needs are met. Additionally, It was observed that in between-meal nourishment or snacks were not made available for all residents in care. This poses an immediate health and safety risk to residents in care.
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ADministrator also stated new cooking staff will be hired. POC shall be submitted to Cynthia.tamayo@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/19/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250919152014

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: 13DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Isikeli Tuikenatabua (Tui) TIME COMPLETED:
01:25 PM
ALLEGATION(S):
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2
3
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9
Staff sexually abused a resident
Staff did not ensure that facility is maintained clean
Staff did not ensure that resident's incontinence needs are met
Air conditioner is not in good working order
INVESTIGATION FINDINGS:
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On 12/4/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez arrived unannounced to conduct a complete and close/deliver complaint investigation findings into an allegation noted above. LPA met with administrator, Isikeli Tuikenatabua (FDA), and stated the purpose of this visit.

LPA requested the following records for review:
• LIC 500
• LIC 9020
LIC 308

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated.
CONTINUED ON 9099A-D
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20250919152014
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: 12/04/2025
NARRATIVE
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Allegation: staff sexually abused a resident, the investigation
It was alleged that staff sexually abused a resident, the investigation into the above allegation consisted of interviews and record reviews. On 09/29/2025 and 10/07/2025, Resident 1 (R1) was interviewed by the department, R1 reported that they had been inappropriately touched by Staff 3 (S3) on 09/22/2025, after S3instructed by R1 to apply Witch Hazel around her groin area and upper inner thighs. R1 denied penetration and that S3 touched their clitoris. R1 recalled S3 saying, “It’s good for me to massage you” and “Let me know when it feels good,” while applying the Witch Hazel. R1 reported other caregivers do not massage them while applying the Witch Hazel. R1 asked S3 to stop touching her and they did. Based on the interview, the information has no basis to support an allegation of sexual abuse. Four staff (S2,S4, and S5) were interviewed and two residents (R1-R2) of which none reported to have witnessed any staff sexually abuse a resident. Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff sexually abused a resident.

Allegation: Staff did not ensure that facility is maintained clean
It was alleged that staff did not ensure that facility is maintained clean, the investigation into the above allegation consisted of interviews and record reviews .
Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that facility is maintained clean It was, is unsubstantiated.

Allegation: staff did not ensure that residents’ incontinence needs are met
It was alleged that staff did not ensure that residents’ incontinence needs are met, the investigation into the above allegation consisted of interviews and record reviews.
R1 reported there was two occurrences when incontinence care was not met. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming .

Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff did not ensure that resident's incontinence needs are met.
CONTINUED ON 9099A-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20250919152014
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: 12/04/2025
NARRATIVE
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Allegation: Air conditioner is not in good working order,
It was alleged that the air conditioner is not in good working order, the investigation into the above allegation consisted of interviews and record reviews. On 9/29/25, R1-R5 stated the air conditioner is in working order. S2 stated they contacted a maintenance worker the week of 9/15/25 when they noticed the Air conditioner was not operating properly and it was fixed immediately. Based on interviews and observations of the LPA and review of records the allegation the Air conditioner is not in good working order is unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of the above allegations are unsubstantiated, but if any additional information is received this complaint can be amended and the findings can be changed.

There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6