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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920201
Report Date: 06/25/2026
Date Signed: 06/25/2026 06:21:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/24/2026 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20260624193028
FACILITY NAME:LEGACY LANE SENIOR LIVING IIFACILITY NUMBER:
345920201
ADMINISTRATOR:DOWNER, SHANICEFACILITY TYPE:
740
ADDRESS:3039 WALNUT AVETELEPHONE:
(916) 664-3914
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/25/2026
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Deaja Malcolm, CaregiverTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Unlawful eviction notice was issued to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with caregiver, Deaja Malcolm, to open a complaint investigation into the allegation listed above.

During visit, LPA spoke with resident (R1) and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Unlawful eviction notice was issued to resident

LPA observed a "30-Day Notice of Termination of Residency" in R1's possession during today's inspection. LPA observed eviction notice as issued to R1 at the care home address.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
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 3
Control Number 59-AS-20260624193028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY LANE SENIOR LIVING II
FACILITY NUMBER: 345920201
VISIT DATE: 06/25/2026
NARRATIVE
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30-Day Notice of Termination of Residency issued to R1 states the following: "The reason(s) for this Notice are as follows: 1. Repeated and/or serious violations of facility house rules and policies pursuant to Title 22 Section 87224. 2. Failure to comply with the terms of the Admission Agreement despite prior discussions and interventions by facility staff. 3. Conduct and behaviors that interfere with the orderly operation of the facility and the well-being, safety, and comfort of staff and other residents."

LPA did not observe any other reasons listed regarding the justification of the eviction on the notice issued to R1 beyond the statement written above. LPA observed that the reasons listed regarding justification of the eviction on the notice issued to R1 did not include specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons for eviction. LPA also observed the wrong mailing address used for R1's right to file a complaint with the nearest office of Community Care Licensing.

Based on observations and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260624193028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY LANE SENIOR LIVING II
FACILITY NUMBER: 345920201
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2026
Section Cited
CCR
87224(d)
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87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information: (...) (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. (...) This requirement is not met as evidenced by:
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Facility will ensure to comply with Title 22 regulations and the Health and Safety code when drafting eviction notices in the future. Facility will rescind 30-Day Notice of Termination of Residency issued to R1. Facility will provide proof of 30-Day Notice of Termination of Residency issued to R1 being rescinded to LPA by POC due date of July 1, 2026.
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Based on observations and records reviewed, the facility did not ensure to comply with Title 22 eviction procedures when drafting 30-Day Notice of Termination of Residency that was issued to R1, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3