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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342702896
Report Date: 09/17/2026
Date Signed: 09/17/2026 02:55:57 PM

Document Has Been Signed on 09/17/2026 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR/
DIRECTOR:
DONNABELL GALICIAFACILITY TYPE:
740
ADDRESS:1922 Morse AVETELEPHONE:
(916) 482-7745
CITY:SacramentoSTATE: CAZIP CODE:
95825
CAPACITY: 160CENSUS: 76DATE:
09/17/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shelly Cha, Christine Soriano, Mery Lyn OteroTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On September 17, 2026, a virtual non-compliance conference was held via Microsoft Teams to discuss the substantial non-compliance history. The licensee has been cited forty-one (41) Type A deficiencies since licensure date of December 20, 2024. Present in today's meeting are Community Care Licensing (CCL) representatives: Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Stephen Richardson, LPM Liza King, LPM Lisa Rios, Licensing Program Analyst (LPA), Christina Valerio, LPA Reza Jamaly, LPA Kimberly Viarella,  and LPA Pang Lee; Long Term Care Ombudsman, Ron Carrera; Legacy Oaks of Sacramento Representatives: Licensee Shelly Cha, Licensee Christine Soriano, Regional Director Mery Lyn Otero, and Legal Counsel Jake Reinhardt

This Noncompliance Conference was called to discuss the following issues or deficiencies:
Forty-one (41) Type A Deficiencies Cited since licensed date of December 20, 2024, Incidental and Medical, Medications, Personnel Requirements - Training, Reappraisals, Basic Services, Activities, Transportation, Memory Care, Laundry Services, and Financial Monitoring effective 05/12/2026
Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:
  • Submit copy of contract with Allen Flores Management Consulting by COB 10/02/2026
  • Submit Initial Training related to assessments for prospective Health and Wellness Coordinator by 10/02/2026 and then every six (6) months
  • Submit copy of initial on-boarding staff training checklist by 10/02/2026


Continues on LIC 809 - C...
Stephen Richardson
Christina Valerio
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2026
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  • Submit staff training regarding Assessments/ Reappraisals by 10/02/2026 and then every six (6) months
  • Submit staff training regarding medications by 10/02/2026 and then every six (6) months
  • Submit plan to address laundry services by 10/02/2026
  • Submit plan to address HVAC/ Air Conditioning System by 10/02/2026
  • Submit plan for activities and transportation services by 10/02/2026
  • Submit an updated emergency disaster plan by 10/02/2026
  • Submit copy of updated liability insurance by 10/02/2026
  • Submit copies of current invoices for USA Waste, SMUD, PG&E, and Consolidated Waste by 10/02/2026.
  • Notify CCL of when Activity Director has been hired
  • Licensee stated they have implemented training every other week. Licensee to provide these training to LPA during quarterly visit

CCL will do the following:
  • Continue increased quarterly monitoring for the next two (2) years
  • Continue to collaborate with facility licensee and staff

This report was read to Licensee Shelly Cha and Licensee Christine Soriano  via cell phone. A copy of this report was provided via email with a signature request from the licensee. Licensee to send signed copy back to LPA Valerio.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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