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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 07/08/2026
Date Signed: 07/08/2026 03:55:46 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
09/15/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250915145921
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 75DATE:
07/08/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Donnabell Galicia, Executive DirectorTIME COMPLETED:
12:43 PM
ALLEGATION(S):
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Staff do not answer resident call buttons in a timely manner.
Staff are not administering medications as prescribed.
INVESTIGATION FINDINGS:
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On 07/08/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to address omissions in the report delivered on 05/15/26 for complaint # 27-AS-20250915145921. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director. LPA met with Donnabell Galicia and a brief interview followed.

The purpose of the report was explained. LPA Viarella substantiated 3 allegations, but cited only for one. This LPA has returned to address the substantiated allegations above.

Regarding: "Staff do not answer resident call buttons in a timely manner."
This allegation was substantiated during the same investigation window in complaint #27-AS-20250910090018, and the allegation was cited on 09/10/25. The same allegations, cited within 5 days of each other do not incur a second citation.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
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-20250915145921
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: 07/08/2026
NARRATIVE
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Regarding: Staff are not administering medications as prescribed.

This LPA reviewed the Electronic Medication Record for R1 for the month of August 2025, and learned that R1 was not administered the following medications:
BUSPIRONE 10MG TABLET – 2 times
DAPAGLIFLOZIN 10MG TABLET – 3 times
DIVALPROEX SOD DR 250MG TABLET – 9 times
GABAPENTIN 400MG CAPSULE – 1 time
INCRUSE ELLIPTA 62.5MCG BLST W/DEV – 1 time
LANTUS SOLOSTAR 100UNIT/1ML INSULN PEN – 1 time
LISINOPRIL 10MG TABLET – 2 times
MIRTAZAPINE F/C 45MG TABLET – 4 times
NICOTINE PATCH STEP 1 21MG24H PATCH TD24 – 5 times
To summarize, R1 was not administered prescribed medications 28 different times during the month of August 2025. The facility failed to ensure that R1’s prescribed medications were available for administration. As a result, the resident missed ordered doses when medication was not timely ordered/and or obtained from the pharmacy. This deficiency has been cited on the LIC 9099D page.

According to the California Code of Regulations Title 22, no other citations were cited during this visit, a copy of this report was provided along with APPEAL RIGHTS, and an exit interview was conducted with Galicia.


SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250915145921
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: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2026
Section Cited
CCR
87465(a)(1)
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87465 (a) A plan for incidental medical ... and provide for assistance in obtaining such care...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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The Executive Director (ED) stated that they are condcuting med tech training on a monthly basis. ED will send a draft of monthly trainings for the next 6 months to this LPA at Kimberly.viarella@dss.ca.gov by the COB 07/09/26.
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Based on a review of records, R1 was not administered prescribed medications 28 different times during the month of August, 2025. This posed an immediate 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3