342701615-7-24-2026-27-AS-SRIN-DWPR6K-20260806124453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701615
Report Date: 07/24/2026
Date Signed: 07/24/2026 06:59:01 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
02/11/2026 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20260211124754

FACILITY NAME:	LEGACY LANE SENIOR LIVING III		FACILITY NUMBER:	342701615
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	9442 MAZATLAN WAY		TELEPHONE:	(564) 200-1736
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Kirk Campbell		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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The Administrator is not present at the facility for a sufficient amount of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff Kirk Campbell, and explained the purpose of today's visit. LPA Valerio spoke to Assistant Administrator Esther Tabua via cell phone. She designated staff to sign on her behalf.

The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility.

Allegation: The Administrator is not present at the facility for a sufficient amount of time.

According to an interview with staff, Administrator Moria comes once a week to assisted staff with administrative duties. LPA Valerio interviewed five (5) residents. Three out of five residents did not know anyone by the name of Moria and the other two residents were unable to provide a response.

Continues on LIC 9099 - C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

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 5

Control Number 27-AS-20260211124754

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 III	FACILITY NUMBER: 342701615
	VISIT DATE: 07/24/2026

NARRATIVE

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LPA Valerio conducted two unannounced visits on 02/17/2026 and 07/24/2026. Administrator Moria was not present for either visit. On 06/16/2026, LPA Jamaly and LPA Villanueva conducted an unannounced visit and Administrator Moria was also not present for the visit.

On 07/21/2026, LPA Valerio attempted to contact the facility and was unsuccessful in reaching any staff person. On 07/22/2026, LPA Valerio attempted to find contact information for Administrator Moria; however, there was none on file. On 07/23/2026, LPA Valerio emailed the facility requesting a call back.

According to the LIC 500, Administrator Moria Gaunavou started on 09/23/2025 and is scheduled from Monday 1:00 PM to 5:00 PM and Thursday 1:00 PM to 5:00 PM.

According to the LIC 500 dated 06/11/2026, there is a new administrator by the name of Shanice Downer. According to an interview with Administrative Assistant Esther Tabua, she is unaware of the number for Shanice Downer.

LPA Valerio requested a copy of the staff file for Shanice Downer. The staff was unable to locate or provide the file to LPA Valerio. A search was conducted to determine if Shanice Downer had an active administrative certificate. It was discovered that Shanice does not have an active certificate. Therefore, the facility does not have a designated administrator to oversee facility operation.

Based on records review, interviews, and LPA observation, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20260211124754

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 III	FACILITY NUMBER: 342701615
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/27/2026 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a)...The administrator shall.. shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a 40 hour Administrator plan by POC due date to LPA Valerio
	8 9 10 11 12 13 14	Based on interviews, records review, and LPA observation, the licensee did not ensure there was a certified administratior on the premises, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/11/2026 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20260211124754

FACILITY NAME:	LEGACY LANE SENIOR LIVING III		FACILITY NUMBER:	342701615
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	9442 MAZATLAN WAY		TELEPHONE:	(564) 200-1736
CITY:	ELK GROVE	STATE:CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS:	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with direct care staff, Omar, and explained the purpose of the visit.

The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility.

Allegation: The facility allowed excluded individuals to work in the facility.

On 02/17/2026, LPA Valerio conducted an unannounced visit. LPA did not observe excluded individuals present in the facility. LPA Valerio interviewed residents and staff. All interviews concluded that they do not know who the excluded individuals are and have not seen them in the facility. On 07/24/2026, LPA Valerio conducted an unannounced visit. LPA did not observed excluded individuals present in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

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 5

Control Number 27-AS-20260211124754

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 III	FACILITY NUMBER: 342701615
	VISIT DATE: 07/24/2026

NARRATIVE

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Allegation: Staff are forging resident documents

LPA Valerio reviewed the LIC 602 for Resident 1 (R1) to Resident 5 (R5). LPA Valerio confirmed that each LIC 602 had a signature from a medical professional. LPA Valerio attempted to confirm the validity of the signatures; however, LPA was unable to confirm or deny that the signatures were valid.

Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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