<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 09/15/2026
Date Signed: 09/15/2026 04:41:39 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
04/30/2026 and conducted by Evaluator Reza Jamaly
COMPLAINT CONTROL NUMBER: 27-AS-20260430150458
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:
09/15/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Memory Care Director Shreetika ChandTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/15/2026 at 2:00 PM Licensing Program Analyst (LPA) Reza Jamaly arrived unannounced at the facility to deliver investigation findings regarding allegations noted above and met with Memory Care Director Shreetika Chand and explained the purpose of the visit.

To investigation the complaints, LPA Jamaly conducted interviews with staff, facility's current management team and reviewed records.
During interview with LPAs Jamaly and Christina Velario, Staff 1 (S1) stated I was hired as a Behavioral Specialist (BS) under previous management, but I am doing caregiving job. I am still listed as BS but not actually doing that role. I got my training at that time. In a separate interview with LPA Jamaly on 8/10/2026, S1 stated that I heard from S2 that management placed S2 on the floor without training.
LPA Jamaly interviewed Staff 2(S2) who stated I was hired as BS, but I never worked at this role, Merylyn Otero was BS supervisor at that time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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 4
Control Number 27-AS-20260430150458
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: 09/15/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2
S2 explained that I got some training on Relias but did not receive floor training although it was not my responsibility, but they placed me on the floor to do care without training. Executive Director (ED), Donnabel told us to do the job, or you will be fired.
S3 also confirmed the allegation and stated I observed a newly hired caregiver being placed on the floor and that the caregiver expressed frustration about short staffing and feeling overwhelmed. S3 did not recall the staff member's name.

LPAs Jamaly and Christina Valerio interviewed Executive Director (ED) Donnabell Galicia, who has been hired a week before the complaint is filed. ED explained the hiring and training procedure and stated "newly hired staff, first get training on Relias, then depend on the position they go out on the floor and shadow, occasionally for few hours. For medication technicians, they get training on Relias then they shadow other med tech for 5 days then they get observed on the cart. 
LPAs asked if med techs doing care? ED stated they do 30 days care training before they do the med tech job. This is a way to get to know the residents.
ED added that all staff including BS, med techs should be aware that they should do care in case of need. When asked if there were any new staff placed on the floor? There was a pause during the questions then stated only in emergencies they would be placed on the floor if we did not have enough people.

On 5/4/2026 LPAs Jamaly and Christina Valerio interviewed Merylyn Otero who previously was working as Regional Manager and currently working as Regional Resident Services Director (RRSD). RRSD stated that there were some new hired staff that were hired by Resident Administrator/Financial (RD), and then we shifted to what we believe fits, for example S2 was hired as a med tech but we don't have position for it, and we only have caregiver position.
RRSD acknowledged placing newly hired staff on the floor and stated " I caught them when RD put them on the floor. I noticed that they were on the floor, and I asked why they were on the floor and pulled them off the floor when I noticed that".
During a separate interview with LPA Jamaly on 9/11/2026, RRSD reported that RD was hiring RD's family and friends without actual availability of positions at the facility, we had to shift those staff to different role.

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

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260430150458
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: 09/15/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3

LPA reviewed Employment Applications of S2, S3, and S4. S2 position listed as caregiver, but during interview with LPA Jamaly, S2 denies being hired as caregiver and stated I was hired as BS, my signature on the form is forged.
Per facility Weekly schedule for the month of April 2026 and first week of May 2026, S2 scheduled to shadow other staff on April 28, 29, 30 and May 1, 2026. Also, Per Relias record, S3 received only 7 hours of training.

Based on interview conducted, document reviewed, facility placed newly hired staff on the floor without training So, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Merylyn Otero and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. 
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Reza Jamaly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20260430150458
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: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2026
Section Cited
CCR
87411(d)
1
2
3
4
5
6
7
87411 Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them..
This requirement was not me as evidenced by:
1
2
3
4
5
6
7
The Licensee/Administrator will ensure that all personnel receive appropriate on-the-job training or have related experience before being assigned duties.
The Licensee/Administrator will review the personnel files of all direct care staff, medication technicians, and behavioral specialists to ensure that relevant training has been provided and properly documented. Copies of the completed training records will be submitted to LPA Jamaly by the POC due date.
8
9
10
11
12
13
14
Based on interviews conducted with staff and management and review of facility records, the facility failed to ensure that newly hired staff received required on-the-job trainings which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4