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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342702896
Report Date: 10/23/2025
Date Signed: 10/23/2025 06:23:09 PM

Document Has Been Signed on 10/23/2025 06:23 PM - 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 OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR/
DIRECTOR:		JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
9164827745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 160CENSUS: 80DATE:
10/23/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Jonathan Aguilar, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/23/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a follow up a case management visit regarding the deficiencies observed during a complaint investigation (# 27-AS-20250804095207) visit on 08/06/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED). LPA met with ED Jonathan Aguilar and Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID).  A brief meeting followed. 

During this LPA's tour of the facility on 08/06/25, this LPA observed the following:
LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in room (#37). These were violations of the California Code of Regulation (CCR) 87309,  "Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage."

This LPA also observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock.  No staff were present in the medication room or the room that was being used as an office attached to it. This was a violation of CCR 87465 "Incidental Medical and Dental, "(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible
for the supervision of the centrally stored medication."
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 10/23/2025
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When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound. This was a violation under Health and Safety Code, "1569.699(a) Exit doors; egress-control devices of time-delay type; fences.  H&S 15699(a) states, "(a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements:…"

LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office within, were open and a file drawer was left open leaving residents confidential financial information accessible. This was a violation under Additional Personal Rights of Residents in Privately Operated Facilities CCR, 87468.2 "(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law."

These deficiencies were cited on the attached LIC 809D pages. 

LPA also observed during today's visit that an Activities Director/Life Enrichment Coordinator has not been hired yet. The previous person was laid off in September. LPA asked the ED what plans were in motion to fill the position. LPA provided technical assistance and referred to CCR Planned Activities 87219
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:
(1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to:
(A) Group discussion and conversation.
(B) Reminiscence activities, such as looking at photos, letters, or greeting cards.
(C) Cultural and/or religious activities, such as holiday celebrations and cultural traditions.
(D) Other social activities such as arts, crafts, games, gardening, pet care, and other recreational activities promoting social interaction.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 06:23 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/23/2025 at 03:31 PM
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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
CCR
87309(a)

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"Storage Space and Access (a) Except as specified in subsection (b)...cleaning solutions, poisonous substances...danger to residents are in locked storage and are not left unattended if outside the locked storage."
The Licensee did not meet the above requirement when:
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The ED stated that the locks on the laundry room (and Business Office ) have been replaced with key codes and now the doors lock automatically upon closing.

LPA observed locks during this visit. This POC has been cleared.
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LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in the bathroom of the behavioral intervention room (#37). This posed an immediate risk to the health safety and personal rights of residents in care.
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Type A
10/24/2025
Section Cited
CCR87465(h)(2)

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87465 "Incidental Medical and Dental (h) The following requirements shall apply...(2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

The Licensee did not meet the above requirement when:

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ED stated this occurred during his paternity leave and he learned that staff had been getting contradictory information about the appropriateness of keeping the med room door open. Since then there has since been additional training and the lock on that door has also been changed to lock upon closing.
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This LPA observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock.
This posed an immediate risk to the health safety and personal rights of residents in care.


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The ED will submit the updated Med Room Policy to CCL by COB 10/24/25 as well as signature sheets for addtional training to be completed by 10/30/25. These documents will be submitted to CCLASCPSacramentoRO@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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 06:23 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/23/2025 at 03:37 PM
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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2025
Section Cited
HSC
15699(a)

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15699(a) states, "(a) When approved by the person responsible...special egress-control devices of the time-delay type, ...The devices shall conform to all of the following requirements:…"

The Licensee did not meet the above requirement when:
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ED stated that they will submit the updated policy regarding the use of the delayed egress door by tomorrow COB 10/24/25 and will supply signature sheets from staff training to be completed by 10/24/25. These documents will be emailed toCCLASCPSacramentoRO@dss.ca.gov.
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When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound.
This posed an immediate risk to the health safety and personal rights of residents in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 06:23 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/23/2025 at 03:46 PM
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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2025
Section Cited
CCR
87468.2(a)(2)

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Additional Personal Rights of Residents in Privately Operated Facilities CCR 87468.2 "(a) In addition... Residents in All Facilities...rights: (2) To have their records and personal information remain confidential... The Licensee did not meet the above regulation when:
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The ED stated that the locks on the laundry room (and Business Office ) have been replaced with key codes and now the doors lock automatically upon closing.

LPA observed locks during this visit. This POC has been cleared.
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LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office inside, were open and a file drawer was left open leaving residents confidential financial information available.
This posed a potential threat to the health, safety and personal rights of residents in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 10/23/2025
NARRATIVE
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(2) Daily living skills/activities which foster and maintain independent functioning.
(3) Cognitive and mental stimulation activities such as reading, writing, movies, crossword puzzles, board and card games, and using the computer.
(4) Sensory stimulation, such as music therapy and aromatherapy, or tactile activities, such as pet therapy. (5) Leisure time activities cultivating personal interests and pursuits, and encouraging leisure-time activities with other residents.
(6) Physical activities that maintain physical health including games, sports, exercises, and other similar activities that promote balance, strength, coordination, flexibility, and range of motion.
(7) Education, achieved through special classes or activities.
(8) Provision for free time so residents may engage in activities of their own choosing.
(b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities.
(c) The licensee shall arrange for utilization of available community resources through contact with organizations and volunteers to promote resident participation in community-centered activities which may include:
(1) Attendance at the place of worship of the resident's choice.
(2) Service activities for the community.
(3) Community events such as concerts, tours and plays.
(4) Participation in community organized group activities, such as senior citizen groups, sports leagues and service clubs.
(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months.
(e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program.
(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 10/23/2025
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available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.

LPA requested a plan be submitted to Community Care Licensing for how/when the facility will fill the full-time 40 hour, on site, position ensuring that the candidate meets all of the qualifications required in Title 22.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Aguilar and Sylve.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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