342702896-5-21-2026-27-AS-SRIN-DWXQGJ-20260814120938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 05/21/2026
Date Signed: 05/21/2026 01:18:32 PM

Unsubstantiated

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
03/05/2026 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20260305151149

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	ROSALIE SULLIVAN		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 82	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Donnabell Galicia		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

The investigation consisted of record reviews of Resident 1’s (R1) death certificate, R1 Death report and medical assessment records.

The Department reviewed the Death Report of R1, dated on 3/5/2026, which says" R1 had numerous medical diagnoses, related to the cancer, such as monoclonal gammopathy, basal cell carcinoma, and Lymphocytosis".

Continues on LIC 9099- C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20260305151149

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: 05/21/2026

NARRATIVE

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Continued from LIC 9099

The department reviewed R1's Medical Assessment, which states" R1 is diagnosed with severe protein-calorie malnutrition, NSTEMI (non-ST-elevation myocardial infarction), CHF (congestive heart failure), schizophrenia in remission, orthostatic hypotension, tardive dyskinesia, dysphagia, and HLD (hyperlipidemia). R1 takes medication and requires assistance with medication management. R1 uses a walker and wheelchair due to motor impairment/paralysis and has a history of skin condition breakdown…".
Additionally, department reviewed R1 Death Certificate, which states " R1 immediate cause of death is listed as non-ST-segment elevation myocardial infarction, with a time interval between the onset and death noted in days. The underlying conditions contributing to R1 death are anemia, with the time interval between the onset and death noted in months, and coronary artery disease, with the time interval between the onset and death noted in years. Other significant conditions contributing to R1 death, but not resulting in the underlying cause, are chronic lymphocytic leukemia".

Due to above note information, the Department concluded the following:

“Resident 1’s (R1) death certificate states [R1] immediate cause of death as non-ST-segment elevation myocardial infarction, with the time interval between the onset and date noted in days. There are no indications that R1’s death was questionable.”

Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

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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
03/05/2026 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20260305151149

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	ROSALIE SULLIVAN		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE:CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 82	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Donnabell Galicia		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not properly report an incident involving a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

LPA Jamaly and LPA Valerio reviewed the facility file and all correspondence related to the incident. LPAs reviewed an email sent by Staff 1(S1) to LPA Christina Valerio on March 5, 2026 regarding the resident’s passing. Additionally, LPAs obtained and reviewed the Death Report dated 3/5/2026. The Death Report documented that Resident 1 passed away on 3/5/2026 at 7:08 AM. Community Care Licensing (CCL) received the report on the same day, meeting reporting requirements.

Based on the information obtained during the investigation, the allegation is determined to be unfounded. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. Per California Code Regulations (CCR) - Title 22 - no deficiencies were cited today. An exit interview was held with Administrator Donnabell Galicia, and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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