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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 10/03/2025
Date Signed: 10/03/2025 11:28:40 AM

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
07/25/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250725171604
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 80DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ashley SylveTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not ensure that facility A/C is operable.
INVESTIGATION FINDINGS:
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On 10/3/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Arvin Villanueva made an unannounced visit to this facility to close and deliver investigation findings into the above allegation. LPAs identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPAs met with DFA, Ashley Sylve, and a brief meeting followed.

It was alleged that staff did not ensure that facility A/C is operable. on 7/29/25 and 8/21/25, LPA Tamayo toured the facility including common areas and resident bedrooms. During the facility tours, it was observed resident rooms were between 78- 85 degrees, however, it was observed that the temperature was over 85 degrees in common areas such as the hallway near the dining room and server room on these dates, which is not within Title 22 regulations.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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-20250725171604
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: 10/03/2025
NARRATIVE
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On 8/25/25 the outdoor temperature was 105 degrees F* and the facility interiors (bedrooms and common areas) were not 30 degrees below outdoor temp (75 degrees). The use of the Infrared thermometer gun, wall thermostats, and observations were used to determine temperatures. Staff interviews, resident interviews, and observations determined that at least two thermostats in the hallway and three resident bedrooms were not functioning properly.

Residents and staff confirmed staff are verbally notified if their room is not cooling, in which a maintenance ticket is created and the maintenance worker offers to install a standing/portable AC units and /or fans.

Staff have placed standing/portable AC units in resident rooms when the central AC is not cooling all rooms properly, in which portable cooling units or switching rooms were offered to residents. Staff reported that historically the AC has not operated as it should, especially in the summertime and have put standing AC/portable AC units and/or fans in resident bedrooms as needed as a temporary solution. Staff admitted the AC unit is not always in working in good condition and there is an ongoing issues with the AC unit in the building. On 8/21/25, the DFA stated the facility was in the process of obtaining bids to install a more permanent solution in the server room and hallway area in which there is lack of ventilation as well as possibly some swap coolers. During this visit, on 10/3/25, DFA stated the facility is actively working to resolve the AC unit issue and there is improvement on this matter. DFA also stated the facility started to routinely change out air filters as of 9/15/25. DFA stated that changing out air filters has helped the AC unit function properly, as it is not working as hard. The facility is able to maintain an average between 75-80 degrees in the past month. Residents in rooms 36-71 have been relocated as the rooms are undergoing renovation to ensure all furnishings are operating properly, including the air conditioner and plumbing. Based on observations, record review, and interviews, the allegation that staff did not ensure that facility A/C is operable SUBSTANTIATED.

Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTANTIATED. one deficiency was cited (See LIC809D). An exit interview was conducted with DFA and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/25/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20250725171604

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 80DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ashley SylveTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are administering the incorrect medication to residents in care.
INVESTIGATION FINDINGS:
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On 10/1/25 Licensing Program Analysts (LPAs) Cynthia Tamayo and Arvin Villanueva made an unannounced visit to this facility to complete and close and deliver investigation findings into the above allegations. LPA identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPA met with DFA, Ashley Sylve, and a brief meeting followed.

It was alleged that staff are administering the incorrect medication to residents in care. 5 staff interviews and 10 client interviews where held on 7/29/25 and 8/21/25, of which, none reported that incorrect medication to residents in care.

However, these interviews did reveal concerns around the issues with delayed medications refills resulting in missed medications and medications missing are not being addressed.

Continued on 9099-A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250725171604
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: 10/03/2025
NARRATIVE
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On 08/13/25, Licensing Program Analyst (LPA) Kimberly Viarella substantiated an allegation that staff are mismanaging resident's medications. Additionally, LPA Viarella is working with the facility to address issues around the facility not submitting timely reporting requirements.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred at this time. Based on observations, record review, and interviews, the allegation that staff are administering the incorrect medication to residents in care is UNSUBSTANTIATED but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies cited per California Code Regulation, TITLE 22 regarding this allegation.
Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250725171604
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: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87303
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The facility shall submit a plan for the repair and/or replacement of the air conditioning system to ensure the facility has an adequate cooling system in good working order along with documentation of the service invoice or technician report by POC due date. In the interim, the
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This regulation was not met as evidenced by based on observation and interviews that took place on 7/29/25 and 8/21/25, which corroborate the conditioning system was not fully functioning and maintained in good repair especially on dates of exreme heat. Additionally, one hallway area was recorded to be over 85 degrees on these dates. This poses an potential health and safety risk to residents in care, especially those with medical conditions impacted by heat.
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 facility will implement and document temporary cooling measures (e.g., portable air conditioners, fans, relocating residents to cooler areas) to ensure resident comfort and safety.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5