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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 06/26/2026
Date Signed: 06/26/2026 01:32:46 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
01/09/2026 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260109133945
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: 82DATE:
06/26/2026
UNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:D GaliciaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not administer resident's medication as prescribed.
Staff mismanages resident's medication.
INVESTIGATION FINDINGS:
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On 6/26/2026, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for this complaint investigation. LPA met with Administrator and explained the purpose of the visit.

Allegation: Staff did not administer resident's medication as prescribed.
On 1/14/26 LPA Viarella reviewed the following medication logs for R1. R1 was prescribed PRN Stomach Relief 262mg/15ml oral suspension to be taken 30ml by mouth every hour as needed for stomach upset. Facility did not have it available during this review. Facility has on hand a Geri Lanta 400mg (RX2613946270) for upset stomach. This medication is not listed in MAR nor in the prescription list dated 12/29/25. R1 also showed a PRN for the Calcium Carbonate 200mg chew tab to be taken 2 to 4 tablets by mouth as needed for acid reflux, this medication is not listed in MAR. Per interview with med tech on duty, it was stated that R1 has not taken this in a while but cannot confirm if there is a discontinue order from the doctor. For the PRN Benzonatate 100mg capsule to be taken 1 cap by mouth every 6 hours as needed for cough, this medication was not available during this visit; med tech is unable to confirm if it was discontinued. Based on record reviewrd, the above allegation is substantiated. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
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-20260109133945
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: 06/26/2026
NARRATIVE
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Allegation: Staff mismanages resident's medication.

On 12/18/25 LPA Viarella asked the ED to define what his understanding of a medication error was. ED replied to the following: wrong dose, wrong resident, wrong time (not in the window, an hour before or after the prescribed time) or if was supposed to be given every 6 hours and we gave it every 8 and no order is on file for the medication. LPA requested files for Residents R1 - R8. The ED told LPAs that they did not have proper PRN release form on file for every resident. ED told LPAs that they do have documentation for all the shadowing required for med techs. Based on record review and interview with ED the above allegation is substantiated.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above is SUBSTANTIATED.

The following deficiency, 87465(e) (1-4) is cited per California Code of Regulations, TITLE 22, DIVISION 6, CHAPTER 8 Article 8.

This is a repeat violation and needs a civil penalty assessed.

Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260109133945
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: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2026
Section Cited
CCR
87465(e)(1-4)
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(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2)The exact dosage.(3) The minimum number of hours between doses.(4) the maximum number of doses allowed in each 24-hour period.
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Med-tech in-service training will be conducted on the POC date if additional time is need the facility will send an email to the LPA to request additional time.
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This requirement was not met as evidenced by med pass observations and records reviewed. medication were not recorded as required and not given as ordered
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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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3