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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 08/13/2026
Date Signed: 08/13/2026 03:24:07 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
03/23/2026 and conducted by Evaluator Reza Jamaly
COMPLAINT CONTROL NUMBER: 27-AS-20260323125642
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 75DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Memory Care Direct Shreetika ChanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not accepting resident back to facility.
INVESTIGATION FINDINGS:
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This is a superseded report that includes supplimental information provided by Responsible Party1 (RP1) and reflects a change in the investigation findings from UNSUBSTANTIATED to SUBSTANTIATED.

On 8/13/2026 at 9:40 AM, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver the complaint findings regarding the allegation listed above. LPA Jamaly met with the Memory Care Direct Shareetika Chand and explained the purpose of the visit.
To investigate this allegation, LPAs conducted interviews, observed the facility, and reviewed relevant resident records, including medication records, incident reports, appraisal information, the admission agreement, and the resident's care plan.
As part of the investigation, LPA Jamaly contacted the Reporting Party (RP). RP stated that R1 was transported to the hospital due to agitation on 3/17/2026 and again on 3/18/2026. RP stated that R1 was tested for a urinary tract infection (UTI) and prescribed medication.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
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 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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RP further stated that, the patient brought to hospital due to agitation on 3/17/2026 and then on 3/18/2026. Patient was tested for UTI and prescribed medication, and the resident didn't need 1:1 care after she we stabilized. I talked to them to accept the resident, follow the prescription order until you coordinate with responsible party or until another community care provider can be found, but they refused to accept her.”

RP further stated that “you know it is hard to find a community care provider for residents who are on Medi-Cal. I wanted the resident to be accepted until another provider could be located and while coordinating with the responsible party and processing the eviction policy. I emphasized that the patient doesn't need 1:1 care and could be taken back to the facility, but they refused to accept her.


On 3/24/2026 at 12:28 PM, LPA Christina Valerio received a telephone call from the facility's former Acting Administrator, Rosalie. Rosalie stated that R1 could not be accepted back from the hospital because R1 was not stabilized and the facility could not meet R1's needs at that time. Rosalie stated that R1 had been sent to the hospital after hitting staff members and was not at R1's baseline. Rosalie stated that she had requested documentation from the hospital but had not received the requested progress notes. Rosalie also stated that she had assessed R1 at the hospital and observed that R1 required a one-to-one sitter. Rosalie stated that the facility could not safely provide one-to-one staffing for R1. Rosalie further stated that she had spoken with the Long-Term Care Ombudsman (LTCO) regarding R1's situation. Rosalie stated that she wanted R1 to receive appropriate treatment and that the facility would accept R1 back if R1 returned at an assisted-living level of care that the facility could safely support.
On 7/16/2026, LPA Jamaly interviewed the LTCO Sacramento Supervisor regarding the conversation described above. The LTCO Supervisor stated that he did not recall the specific conversation at that time and would review his records. He further stated that he was not in a position to agree or disagree with the facility regarding whether R1 could safely return to the facility.

On 7/16/2026, LPA Jamaly interviewed staff 1 (S1). S1 stated that Resident 1 (R1) was so aggressive, ending up in hospital three times a week. I think R1 should not be admitted here because R1 was hitting care staff, another residents, refusing medication, and was eloping. We changed R1 room to prevent hitting other residents, but it did not work.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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page 3

S1 added that on 3/18/2026 I witnessed R1 hit paramedic in the head with a vase when Alpha one trying to transport her to ER and in another incident R1 eloped and was found near Target store. S1 does not remember the exact date of R1 eloping.

LPA Jamaly interviewed Executive Director (ED) Donnabell. ED stated that she was not employed at the facility at the time of the incident. However, based on discussions with facility staff, ED understood that R1 had not been formally evicted but was not accepted back because the facility determined that it could not meet R1's needs, specifically the need for continuous one-to-one staffing.
On 8/10/2026, LPA Jamaly interviewed Responsible Party 1 (RP1) regarding the allegations. RP1 stated that the facility did not notify RP1 regarding R1's eviction or the facility's decision not to accept R1 back. RP1 stated that RP1 learned about the situation through Kaiser Permanente Hospital. RP1 stated that R1 had resided at the facility for approximately five years and had become increasingly combative after not receiving prescribed medications. RP1 also stated that the facility had failed to properly submit R1's paperwork to Social Security and Medi-Cal, which resulted in the loss of benefits. RP1 stated that RP1 eventually assisted R1 in reinstating the benefits.
RP1 stated that Kaiser Permanente assisted in locating another facility for R1, where R1 is currently receiving medications and doing well. RP1 denied that R1 lacked adequate clothing and stated that RP1 had purchased multiple sets of clothing and other personal belongings for R1. RP1 stated that, after R1 left the facility, the facility did not return R1's clothing and personal belongings.
Regarding the allegation that the facility did not accept R1 back, RP1 stated that the allegation was true. RP1 stated that the facility repeatedly sent R1 to Kaiser Permanente due to aggressive behavior, including one occasion when R1 remained hospitalized for approximately two months. RP1 also reported frequent changes in facility management and staff and stated that the facility did not provide appropriate care or adequately manage R1's paperwork.

LPA Jamaly reviewed incident reports documenting multiple incidents involving R1's aggressive behavior and refusal of medications.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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page 4

LPA Jamaly reviewed R1's Medication Administration Records (MARs). The records indicate that R1 refused multiple scheduled medications during March 2026, including morning and afternoon medications on numerous dates. The records also document that R1 was transported to Kaiser Permanente on 3/16/2026, 3/17/2026, and 3/18/2026 due to agitation and aggressive behavior.
An Incident Report documented that on 3/18/2026, R1 became aggressive and hit a care staff member. Alpha One was called to assist, and R1 subsequently struck a paramedic in the head with a vase. The report stated that Alpha One personnel restrained R1 and transported R1 to Kaiser Permanente Emergency Room for evaluation.
LPA Jamaly reviewed R1's LIC 602A. The document indicates that R1 had diagnoses including schizophrenia, insomnia, constipation, muscle weakness, and dementia, with ongoing agitation and aggressive behaviors.
LPA Jamaly reviewed R1's Admission Agreement. The agreement states that the facility may terminate the admission upon 30 days' written notice when, following reassessment, it is determined that the facility is no longer appropriate for the resident. LPA Jamaly did not locate documentation showing that a 30-day written notice was provided to R1 or RP1 regarding the facility's decision not to accept R1 back.
Additionally, based on interviews conducted during the investigation, the facility did not notify RP1 regarding its decision not to accept R1 back to the facility.
LPA Jamaly reviewed R1's Preplacement Appraisal Information, LIC 603. The document indicates that R1 was unable to follow signals and required assistance with toileting, medication, and health and medical care.

Based on interviews, records reviewed, the preponderance of evidence establishes that the facility did not accept R1 back from the hospital and did not provide evidence that the required eviction/discharge process had been properly followed or that RP1 had been provided the required notice. Therefore, this allegation is Substantiated. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Executive Direct Donnabell Galicia and a copy this report and appeal rights provided to facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2026
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures. The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required..If, after admission, it is determined that the resident has a need not previously identified..
This requirement is not met as evidenced by:
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The Administrator/Licensee will review 87224 Eviction Procedures and Facility Eviction Policy/Admission Agreemtn and sign a statement stating revision completed.
Administrator/Licensee provide training regarding eviction procedures and provide proof of training competion including trainee's name with thier signature, date of traiing and training title.
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Baed on interviews conducted and records reviewed, the licensee didn't comply with section cited above because eviction procedures were not followed and the resident evicted without providing 30 days written notice to the resident.
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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.
SUPERVISOR'S NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
03/23/2026 and conducted by Evaluator Reza Jamaly
COMPLAINT CONTROL NUMBER: 27-AS-20260323125642

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE:CAZIP CODE:
95825
CAPACITY:160CENSUS: DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Memory Care Direct Shreetika ChanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not meet residents’ care needs, resulting in a UTI.
Staff don't answer facility phone.
INVESTIGATION FINDINGS:
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This report is amended to correct the investigation finding from SUBSTANTIATED to UNSUBSTANTIATED. The finding was mistakenly selected as SUBSTANTIATED in error.

On 8/13/2026 at 9:40 AM, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver the complaint findings regarding the allegations listed above. LPA Jamaly met with the Memory Care Direct Shareetika Chand and explained the purpose of the visit.
To investigate this allegation, LPAs conducted interviews, and reviewed relevant resident records, including R1's LIC 602, Care Plan, and Preplacemnet Appraisal Information.

1. Staff did not meet residents’ care needs, resulting in a UTI.
On 5/26/2026, RP returned LPA Jamaly's telephone call. LPA asked RP whether inadequate care at the facility resulted in R1 developing a UTI. RP stated, in substance, that RP did not state that poor care resulted in the UTI.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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RP acknowledged that R1 had been diagnosed with a UTI but stated that RP was not alleging that the UTI resulted from inadequate care.
On 8/10/2026, LPA Jamaly conducted phone interview with S2 and asked whether R1's toileting, grooming, and hygiene needs were adequately met. S2 stated that, generally, caregivers were responsible for meeting R1's needs despite significant staff turnover. S2 also stated that R1 frequently refused care, attempted to elope, and became aggressive when caregivers attempted to assist R1 with hygiene needs. S2 stated that R1 would sometimes slam the door and become aggressive toward staff.

LPA asked S2 whether S2 observed any changes in R1's urine or other signs of a UTI. S2 stated that S2 did not observe changes in R1's urine and did not observe signs of a UTI at that time. LPA asked how frequently R1 was expected to be toileted or have briefs changed. S2 stated that R1 was expected to receive assistance approximately every two hours. When asked whether inadequate care resulted in R1 developing a UTI, S2 stated that S2 did not believe the UTI was caused by staff negligence.

On 8/10/2026, LPA Jamaly interviewed S3. LPA asked whether R1's grooming and toileting needs were met. S3 stated that S3 was unsure because R1 was frequently aggressive, and other staff were sometimes reluctant to provide care. S3 stated that R1 was more receptive to assistance from S3 and that S3 assisted R1 with changing briefs, showering, and other personal care needs. S3 also stated that management requested S3's assistance when R1 eloped.
S3 stated that R1 frequently refused care. When asked what management did when R1 refused services, S3 stated that management considered refusal of services to be R1's right.
LPA asked S3 whether S3 believed inadequate care resulted in R1 developing a UTI. S3 stated that S3 was unsure. S3 reported observing messes in R1's room when attempting to provide care and stated that R1 was not receptive to assistance from other staff.
S3 also stated that R1's personal hygiene declined over time. S3 reported observing that R1 sometimes went several days without changing clothes and believed that R1 may not have had sufficient clothing available.
LPA reviewed R1's LIC 602A, dated 9/24/2025. The document indicates that R1 was unable to independently meet toileting needs but was not bowel or bladder incontinent.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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LPA reviewed R1's Care Plan, dated 2/3/2026. The care plan indicates that R1 required total assistance with personal hygiene and grooming and that staff were to complete skin checks at least twice per week, as needed.
The care plan further documents that R1 did not consistently use the toilet and demonstrated inappropriate toileting behaviors, including urinating on the floor, furniture, or bed. The care plan states that R1 refused to wear incontinence products and was noncompliant with perineal care and cleanup following toileting incidents. Staff were directed to provide verbal prompts, physical assistance as tolerated, redirection, and environmental cleaning to maintain sanitary conditions and reduce the risk of infection.

The care plan also indicates that R1 was physically able but unmotivated to participate in grooming, bathing, and incontinence care and frequently declined assistance or became resistant when prompted. Staff were directed to provide frequent reminders, redirection, and supportive encouragement.
LPA also reviewed R1's LIC 603, which indicates that R1 required assistance with bathing, toileting, hair care, and personal hygiene.

3. Staff don't answer facility phone.

On 5/26/2026, RP returned LPA Jamaly's telephone call. When asked about this allegation, RP stated that the hospital had contacted the facility multiple times regarding R1's pending discharge and current status. RP stated that facility staff did not answer the telephone, which caused frustration.
On 7/16/2026 at 10:26 AM, LPA Jamaly called the facility's telephone number, (916) 482-7745. The call was answered by the front desk. LPA Jamaly called the facility again at 1:04 PM on the same date, and the call was also answered by the front desk.
LPA Jamaly asked ED to provide telephone logs for the period of 3/16/2026 through 3/23/2026. ED stated that there had been significant changes at the facility since March 2026 and that the facility had more than one telephone number.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 27-AS-20260323125642
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: 08/13/2026
NARRATIVE
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On 7/16/2026, LPA Jamaly attempted to contact RP to determine which facility telephone number RP or the hospital had contacted. RP did not answer the call.
Although RP reported that the hospital had difficulty reaching the facility, the investigation did not establish which telephone number was called, the dates and times the calls were made, whether the calls were received by the facility, or whether facility staff intentionally failed to answer the calls.

Based on interviews, observations, and records reviewed, the preponderance of evidence standard is not met. Therefore, the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have occurred or may be valid; however, the evidence does not establish by a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Executive Direct Donnabell Alicia and a copy this report and appeal rights provided to facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 9