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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342702896
Report Date: 05/15/2026
Date Signed: 05/18/2026 11:57:59 AM

Document Has Been Signed on 05/18/2026 11:57 AM - 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:		ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 160CENSUS: 81DATE:
05/15/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shreetika Chand, Memory Care DirectorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 05/15/26, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit related to complaint investigation number 27-AS-20250522140000.  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 Shreetika Chand Memory Care Director (MCD) and Regional Service Director (RSD) and this LPA reviewed the citations to be delivered today as a result of the above mentioned investigation.  A tour was also conducted during this visit.

Through the course of the investigation into the death of a resident (R1), this LPA learned that the required 2 hour checks for 05/03/25 were not conducted as required.  This deficiency has been cited on the LIC 809D page.

LPA reviewed R1s care plans dated 07/12/24, 8/27/24, 10/11/24, 11/08/24, and 03/05/25.  The first 4 care plans all state that R1 required 2 hour checks and was a fall risk, yet even after having falls as documented by incident reports, no changes were made to R1's care plan. There was a slight change to the care plan on 03/05/25 when it was noted on page 3 that R1, "returned from hospital visit from VA with seizure activity and a change in ambulation and locomotion," yet no changes were made to R1's care plan to address R1's propensity to fall.  This deficiency has been cited on the LIC 809D page.

LPA reviewed incident reports for R1. In them, the facility reports that they ran out of R1’s medications.  On 10/18/24 R1 was not administered the following: "cranberry juice cap 425 mg (1&2), Finasteride (10/02/24, 10/11/24, 10/21/24) Flovent 120 mcg/inh (10/23/24 - 10/25/24), Fluticasone (10/15/24 -10/22/24) Folic Acid 1 mg (10/01/24 – 10/11/24) Lamotrigine 200mg (10/02/24, 10/11/24 -10/15/24), Propranolol 80 mg (10/07/24,10/11/24, 10/18/24), Tamsulosin 0.4mg (10/10/24 – 10/15/24), Thera vite max (25) Vitamin b12 500 mg (10/10-/24-10/14/24) for October." On 08/02/24, R1 was sent out for emergency medication refills. 
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/18/2026 11:58 AM - It Cannot Be Edited


Created By: Kimberly Viarella On 05/15/2026 at 11:01 AM
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: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2026
Section Cited
CCR
87464(f)(1)

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Basic Services shall at a minimum include: Care and supervision as defined in Section 87101(c )(3) and Health and Safety Code section 1569.2(c )

The above Requirement was not met as evidenced by:
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The Memory Care Director and Regional Service Coordinator stated they will create a safety check list which will require both staff and management signatures to ensure that all checks are competed as required per care plans. These will be submitted to CCL by the COB 05/16/26.
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Based on interviews and a review of records, staff did not conduct 2 hour checks which were outlined in R1's care plan. This posed an immediate threat to the health, safety and personal rights of residents in care.
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Type A
05/16/2026
Section Cited
CCR87463(g)

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Reappraisals (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident.

The above requirement was not met as evidenced by:
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The Memory Care Director and Regional Service Coordinator stated that they will conduct an audit of all resident files to see which require updated LIC 602s and/or careplans for MC and AL. The Audit for MC will be due by COB 05/16/26. AL will be due
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Based on a review of records, reappraisals did not include a change in the care plan to meet the needs of R1.
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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: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 05/15/2026
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On 03/17/25 R1 the facility reported that the resident was not administered Acetaminophen that they were prescribed to take 3X daily.  All doses were missed on 3/16/25 and 3/27/25 because their medication was out of stock. On 05/03/25, R1 was not administered their morning dose of Lamotrigine Oral Tablet 150 MG because the facility did not ensure that they had a refill on hand . This deficiency has been cited on the LIC 809D page.

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

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/18/2026 11:58 AM - It Cannot Be Edited


Created By: Kimberly Viarella On 05/15/2026 at 11:06 AM
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: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2026
Section Cited
CCR
87465(a)

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 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility.... shall encourage routine medical & dental care & provide for assistance in obtaining such care...
This requirement was not met as evidenced by:

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The Memory Care Director and Regional Service Coordinator stated they have begun retraining all medication technicians and are assigning a # of residents to each medtech so that they will be responsible for ordering their meds. A written update with a plan of completion will be submitted to CCL by COB.
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The above regulation was not met as evidenced by the document review showing that the facility ran out of R1's prescriptions on more than 12 occasions involving 12 different prescriptions.
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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: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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