342702896-8-24-2026-27-AS-SRIN-DXKV9F-20260903161415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 08/24/2026
Date Signed: 08/24/2026 01:08:04 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
08/11/2026 and conducted by Evaluator Reza Jamaly

COMPLAINT CONTROL NUMBER: 27-AS-20260811142302

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	DONNABELL GALICIA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 76	DATE:	08/24/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Donnabell Galicai		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff does not ensure residents' care plan is up to date.
Staff does not ensure resident is provided clean clothing.
Staff does not ensure resident's hygiene needs are being met.

INVESTIGATION FINDINGS:

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On 8/24/2026, Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver the investigation findings regarding the allegations noted above. LPA met with Executive Director (ED) Donnabell Galicia and explained the purpose of the visit.
As part of the investigation, LPA Jamaly conducted interviews, made observations of the facility and R1, and reviewed R1’s records.
1. Staff Does Not Ensure Residents’ Care Plans Are Up to Date

On 8/24/2026, Licensing Program Analyst (LPA) Reza Jamaly interviewed R1’s sister, who is listed as Responsible Party 1 (RP1) and asked RP1 about the complaint. RP1 stated that I did not file the complaint, I learned about the complaint from the Executive Director (ED) and was informed that the complaint was filed by R1’s nephew. RP1 stated that R1 does not have a nephew.
LPA asked whether RP1 had any concerns regarding R1’s care or whether R1 had any immediate needs at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026

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 5

Control Number 27-AS-20260811142302

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: 08/24/2026

NARRATIVE

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RP1 stated that R1 has been receiving hospice services for approximately two months and had previously been hospitalized in the intensive care unit (ICU) for a period of time.

RP1 stated that R1 is currently receiving the care and services needed and does not have any concerns at this time. RP1 stated that facility staff are taking care of R1 and that the ED contacts RP1 approximately once a week to provide updates regarding R1’s condition. RP1 also stated that a staff member recently contacted me and reported that R1 attempted to get out of bed at approximately 3:00 AM, to obtain a cigarette.
LPA explained that R1’s access to cigarettes and a lighter was a concern reported by the facility and asked RP1 who provided R1 with the cigarettes and lighter. RP1 stated that I had provided R1 with cigarettes and a lighter but was subsequently instructed by facility staff not to do so. RP1 stated that I stopped providing cigarettes and a lighter to R1 after being instructed by staff not to do so.
Based on R1 record, R1 is transported to Kaiser Permanente Emergency Department on 7/17/2026. The ER recommended follow-up with R1’s Primary Care Provider (PCP). No medication is prescribed during the ED visit. Hospice information is also provided in the discharge paperwork.
On 7/21/2026, a comprehensive assessment was completed due to R1’s change in condition. The assessment identified R1’s primary diagnosis as Chronic Obstructive Pulmonary Disease (COPD) with acute lower respiratory infection and a mental health diagnosis of Major Depressive Disorder (MDD).
The assessment indicated that R1 requires complete assistance with getting ready for bed, assistance with personal hygiene and grooming, and assistance with bladder incontinence, including assistance from two staff members. The assessment also indicated that staff are to complete skin checks at least twice weekly and as needed. R1 requires assistance with Activities of Daily Living (ADLs), is unable to stand or walk for extended periods, and uses a wheelchair.
LPA Jamaly reviewed R1’s records and observed that R1’s Physician’s Report, LIC 602, was updated on 7/15/2026. The LIC 602 identified R1 as non-ambulatory and listed the following diagnoses: schizophrenia, urinary incontinence, nocturnal enuresis, acquired hypothyroidism, neurogenic bladder, chronic constipation, and other documented conditions. A TB clearance was completed on 7/11/2026. The LIC 602 also documented R1’s physical health status, including bowel and bladder incontinence, motor impairment/paralysis, and the need for assistance with repositioning and transfers. The report also indicated a history of skin conditions or breakdown.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20260811142302

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: 08/24/2026

NARRATIVE

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On 8/13/2026, LPA Jamaly interviewed ED regarding the allegation. ED stated that some residents’ care plans had not been updated and that management was working to update them. However, regarding R1 specifically, ED stated that R1’s care plan had been updated. ED further stated that R1’s family requested that the facility accept R1 in hospice, and the facility requested that an assessment be completed prior to admission. Following the assessment, the facility accepted R1 and provided care while R1 was receiving hospice services.
2. Staff does not ensure resident is provided clean clothing.

On 8/13/2026, LPA Jamaly conducted an observation and interview with R1. LPA observed R1 lying on the bed and receiving oxygen. R1’s bedroom door was open. During the interview, R1 requested that staff change R1’s brief. The caregiver was contacted and subsequently changed R1’s brief.
LPA inspected R1’s bedroom and bathroom and observed the areas to be clean. LPA did not observe an odor of urine or feces in R1’s bedroom.
During the interview, LPA experienced difficulty understanding R1. When questions were repeated, R1 became frustrated. LPA requested assistance from Staff 1 (S1) to facilitate communication. LPA asked R1 whether family members regularly checked on R1. R1 stated that R1’s sister and brother check on R1 and stated that R1 does not have a niece or nephew.
LPA asked R1 how often R1’s briefs are changed, who assists with changing briefs and clothing, and when R1 last received a bath. R1 stated that R1’s briefs are changed approximately three times per day and pointed to S1 as the person who assists with changing R1’s briefs and clothing. R1 could not recall the exact date of the last bath but stated that it occurred a couple of days earlier.
R1 denied experiencing a recent fall and denied having filed a complaint against the facility or staff. When asked about immediate needs or concerns, R1 stated, “I need emergency button. I don’t have one right now.”
On 8/13/2026, LPA interviewed S1, and asked how frequently R1’s clothing and hygiene needs are checked. S1 stated that S1 works on the floor and changes R1’s briefs based on need. S1 stated that three other caregivers also assist with R1’s care. S1 stated that R1’s bedroom door is always open and that staff check on R1 frequently. S1 stated that R1 is not left in wet clothing or briefs.
S1 stated that R1 receives baths based on need but does not take showers because R1 uses oxygen and is bedbound.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20260811142302

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: 08/24/2026

NARRATIVE

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LPA asked S1 whether there were any concerns or needs regarding R1. S1 stated that R1 smokes and believed that R1’s brother and sister provide cigarettes. S1 stated that, on a previous occasion, a medication technician found a cigarette and lighter in R1’s possession. S1 also stated that R1 needs additional clothing, including pants, from the family or facility because the current clothing is stained.

In an interview with Responsible Party 1 (PR1), LPA asked whether R1 had an adequate supply of clothing. RP1 stated that R1 has two bags full of clothing. RP1 explained that R1 is currently not using many of the clothes because R1 spends most of the time in bed.

On 8/24/2026 LPA Jamaly interviewed S2 about handwritten laundry schedule provided by ED and asked if S2 confirm it. S2 confirmed it and stated that R1 laundry is done every Thursday. S2 added that R1 was changing clothes before frequently, but recently is not changing clothes a lot, because R1 is spending most of the time in bed, last Thursday, I just washed linen from R1.

3. Staff does not ensure resident's hygiene needs are being met.
During LPA Jamaly’s observation on 8/13/2026, LPA inspected R1’s bedroom, bathroom, closet, and bed. R1 was observed receiving oxygen, and the bedroom door was open. LPA did not observe any apparent hygiene concerns and did not detect an odor of urine or feces in R1’s bedroom.
During the interview on 8/13/2026, LPA asked R1 how frequently R1’s briefs are changed, who assists with the changes, and when R1 last received a bath.
R1 stated that R1’s briefs are changed approximately three times per day and identified S1 as the person who assists with changing R1’s briefs and clothing. R1 stated that the last bath occurred a couple of days earlier but could not recall the specific date.When asked about immediate needs or concerns, R1 stated, “I need emergency button.”LPA also interviewed S1 regarding R1’s hygiene needs.

LPA also interviewed S1 regarding R1’s hygiene needs.

R1 stated that R1’s briefs are changed approximately three times per day and identified S1 as the person who assists with changing R1’s briefs and clothing. R1 stated that the last bath occurred a couple of days earlier but could not recall the specific date.
When asked about immediate needs or concerns, R1 stated, “I need emergency button.”

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20260811142302

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: 08/24/2026

NARRATIVE

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LPA also interviewed S1 regarding R1’s hygiene needs. S1 stated that R1’s briefs are changed based on need and that three additional caregivers assist with R1’s care. S1 stated that staff check on R1 frequently and that R1 is not left wet. S1 further stated that R1 receives baths based on need but does not shower because R1 uses oxygen and is bedbound.
LPA asked S1 whether S1 had observed any recent change in R1’s condition or any falls. S1 stated that S1 had not observed a change in condition or any falls involving R1.

During interview with ED Regarding the allegations, ED stated that the facility recently terminated an employee and believed that the former employee may have submitted complaints on behalf of residents in retaliation. ED stated that, on a Friday, the police came to the facility and informed staff that an unknown individual had contacted law enforcement and identified sef as R1’s nephew when making the complaint.
ED stated that the facility subsequently asked R1 about having a nephew. According to ED, R1 denied having a nephew and stated that R1 has only a brother and sister.LPA Jamaly also asked ED about the allegation concerning unreported falls involving R1. ED stated that R1 had not experienced any falls at the facility.
LPA Jamaly searched the Department’s shared folder for incident reports involving R1 from March 2026 through 8/24/2026. No incident report documenting a fall involving R1 was located.

Base on the observation, interviews and record review, 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. An exit interview was held and a copy of report provided to the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2026

LIC9099 (FAS) - (06/04)

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