342702896-2-25-2026-27-AS-LKIG-DS9KUQ-20260317081307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 02/25/2026
Date Signed: 02/25/2026 11:00:50 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
07/31/2025 and conducted by Evaluator Noel Wolf Petersen

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250731151014

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	JONATHAN AGUILAR		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(559) 313-8062
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 85	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	08:46 PM
MET WITH:	Rosalie Sullivan		TIME COMPLETED:	08:47 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not properly report incident
Facility staff not answering communications from resident’s representative

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst LPA, Noel Wolf Petersen, arrived unanounced to the facility at 8:45pm to deliver findings of a complaint. LPA Met with administrator by phone and explained the purpose of the visit.

In LPA's Interview with the past Administrator Johnathan Aguilar It was learned that there was a period of time from mid June to mid July 2025, where the facility was shortstaffed and unable to fulfil its regulatory obligations to report to ccl. Record review of the Incident Reports from June-July 2025 showed an observeance of timely reporting until 6/16/2025, and then a period where significant events were not reported to ccl until 7/9/2025. In that time there were 10+ events where a unplanned hospitalization exited the window of time when the event should have been reported to ccl, allong with many, many other types of report that should have been sent to the LPA. Administrator Aguilar provided this period of shortstaffing made it impossible to adequately inform and respond to communications from all resident representatives who's circumstances required notification.
Continued on C- Page

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

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 3

Control Number 27-AS-20250731151014

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 OAKS OF SACRAMENTO	FACILITY NUMBER: 342702896
	VISIT DATE: 02/25/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the departments observations and interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Citations issued on the following d-Page. A copy of the report was read to the administator and given to the administrator representative, with a copy of the appeal rights. exit interview was conducted with the current administrator. designated signatory is staff tammy

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20250731151014

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 OAKS OF SACRAMENTO	FACILITY NUMBER: 342702896
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/26/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Review of Reporting requirements for the situations requiring communication with responsible persons will be reviewed in the mandated reporter training described below.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: record review where 5 of 19 Significant Incident Reports selected randomly from the period of June 2025 to July 2025 where the facilities observed chanage in condition did not also document a notification of the residents responsible person. Interview with a previous administrator who described a period in June 2025-July 2025 where the facility was not staffed adequately to communicate with representatives. Not following this requirement poses an immediate risk to the health, safety, and personal rights clients in care.	8 9 10 11 12 13 14
Type A 02/26/2026 Section Cited CCR 87211(c)	1 2 3 4 5 6 7	87211(c) Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).	1 2 3 4 5 6 7	administrator will conduct a staff mandated reporter training, by 3/6/26. a signature of those attended will be sent to the LPA(noel.wolfpetersen@dss.ca.gov) by eod on 3/6/26.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Record review where 1 of 19 significant Incident reports selected randomily from the period of june 2025 to July 2025 described an incident where one resident physically assaulted another resident 6/27/25, ccl informed and recived report 7/20/25. Interview with a previous administrator who described a period of june 2025-July 2025 where the cacility was not staffed adequately to communicate with ccl Not following this requirement poses a immediate risk to the health, safety, and personal rights clients in care.	8 9 10 11 12 13 14

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: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3