345920201-7-15-2026-59-AS-LCRR-DXCSM2-20260827135914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920201
Report Date: 07/15/2026
Date Signed: 07/15/2026 05:25:56 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
12/12/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20251212164744

FACILITY NAME:	LEGACY LANE SENIOR LIVING II		FACILITY NUMBER:	345920201
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	3039 WALNUT AVE		TELEPHONE:	(564) 200-1736
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	07/15/2026
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Deaja Malcolm, Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident was neglected by staff, resulting in hospitalization
Facility staff mismanaged residents' medications
Facility staff did not treat residents with dignity
Facility staff did not provide adequate food services to the residents in care
Facility staff sleep while on duty
Staff are not ensuring facility is clean and in good repair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with caregiver, Deaja Malcolm, to deliver findings regarding the complaint allegations listed above. LPA spoke with Administrator, Shanice Downer, via telephone call, who gave permission for caregiver to sign report.

During investigation, the Department conducted interviews, toured the premises, conducted a medication count, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

According to facility documents, staff member (S1) was responsible for client care from December 5, 2025 to December 10, 2025. Based on interviews conducted by the Department with resident (R1’s) family and residents in care, as well as facility documents reviewed, R1 needed to be spoon fed their meals.

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

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 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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Residents (R2 and R3) reported that, on December 5, 2025, they informed S1 that R1 needed to be spoon fed their meals. Staff member (S2) reported in their interview that, on December 5, 2025, they stopped by the facility to review files and informed S1 that R1 needed to be spoon fed their meals. S2 reported that no one answered the door for them as they arrived at the care home and they observed S1 lying on the couch, looking at their phone while R1 was sitting at the dining table with food in front of them. S2 stated that they asked S1 what they were doing, and S1 stated that they were on break from cleaning. S2 reported that they asked S1 if they fed R1 and S1 responded, “[R1] can feed themselves.” S2 stated that they explained to S1 that R1 is incapable of feeding themselves and R1 could not eat unless staff spoon feed them, to which S1 responded, “I didn’t know that,” and proceeded to spoon feed R1. S2 stated that R1 “seemed weak” and not at baseline, as well as unkempt in relation to the care provided by Administrator, Moria Gaunavou. S2 stated that they didn’t contact EMS for R1 as they explained that R1’s condition didn’t require medical attention at the time, despite appearing weak and not at baseline.

Between December 6, 2025 and December 7, 2025, R2 and R3 reported to the Department that they witnessed R1 sitting at the dining table around lunchtime with a bowl of untouched oatmeal still in front of them from breakfast. On December 8, 2025 at around 1200 hours, R1’s family visited R1 and found them unresponsive at the dining table with a bowl of oatmeal sitting in front of them. S1 called 9-1-1 and R1 was transported to the hospital. Based on medical records, R1 was diagnosed with severe dehydration, starvation ketoacidosis, urinary tract infection (UTI), and right basilar atelectasis.

S2 visited the facility approximately one (1) week prior to December 5, 2025 and recalled R1 being at baseline, walking, and smiling. R1’s family visited R1 on December 3, 2025 and R1 appeared “normal” and interacting like they typically would.

The Department was unable to locate S1 for an interview regarding the allegations.

Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 did not provide the residents with their medications and residents had to dispense their own medications.

** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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The Department conducted interviews with the residents in care. During interview, R2 stated that they never witnessed S1 give R1 their medications. R3 stated that R1 and resident (R4) never received their medications when S1 was working at the care home. R4 confirmed that S1 did not provide them with their prescribed medications while S1 was the sole caregiver at the care home for approximately four (4) to five (5) days. During interview, resident (R5) indicated that they missed medications while S1 was working at the care home. R1’s Medical Assessment dated September 10, 2025 states that R1 is unable to administer their own prescription medications and is unable to store their own medications. R1’s Admission Agreement dated February 14, 2025 and R1’s Appraisal/Needs and Services Plan dated February 15, 2025 indicated that R1 required staff assistance with all activities of daily living (ADLs). R4’s Medical Assessment dated January 22, 2026 states that R4 is unable to administer their own prescription medications and is unable to store their own medications. R5’s Medical Assessment dated February 5, 2026 states that R5 is unable to administer their own prescription medications and is unable to store their own medications.

During visit conducted on December 17, 2025, LPA conducted a medication count for R1, comparing the resident's Centrally Stored Medication Forms (CSMFs) and Medication Administration Records (MARs) with medications centrally stored for the resident. LPA observed that four (4) of four (4) medications counted for R1 were off count when comparing count to R1’s CSMF and MAR. LPA observed two (2) medications to be over the amount that was documented, and two (2) medications to be under the amount documented. Care home was unable to provide any records during visit to justify medication count being off. During mediation count, LPA observed that R1’s MAR showed signatures from S1 indicating medications were given to R1 while R1 was out of the community due to hospital visit from December 8, 2025 to December 13, 2025. LPA conducted interviews with residents during investigation, including R2, R3, and R4. R2 and R3 reiterated that S1 did not provide assistance with medication administration while being the sole caregiver from December 5, 2025 to December 10, 2025. R3 stated that R4 never got their medications the entire time S1 was working. R4 confirmed with LPA that they did not receive their medications while S1 was working at the care home. R3 stated that medications were accessible to everyone and never locked while S1 worked at the care home.

** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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On April 22, 2026, LPA conducted a case management visit to follow-up regarding observations made during separate inspections conducted on April 21, 2026 and April 22, 2026. During visit conducted on April 21, 2026, LPA observed medications accessible to the residents located in residents' (R6 and R7's) bedrooms. LPA observed R6's nighttime medications pre-poured in R6's bedroom. LPA observed multiple prescription bottles stored in R7's bedroom. Interview with R7 indicated that they had a week's worth of medications pre-poured for them. LPA observed a week's worth of medications pre-poured stored in R7's bedroom. During visit, LPA reviewed records, including four (4) resident records. Per Physician's Report (LIC 602A) dated January 29, 2025, R6 is not "able to store own medications." Per LIC 602A dated December 11, 2025, R7 is not "able to administer own prescription medications," not "able to administer own PRN medications," and not "able to store own medications." Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465 Incidental Medical and Dental Care (h) “The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met based on interviews conducted and observations, which determined that care home did not ensure that residents’ medications were kept in a safe and locked place.

On May 7, 2026, LPA conducted a case management visit in relation to a separate inspection conducted on May 7, 2026. During visit, LPA observed centrally stored medication unlocked and accessible to the residents in care. LPA reviewed resident records and observed three (3) of six (6) residents were assessed to be unable to have access to centrally stored medications. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465(h) based on LPA's observations and records reviewed, which determined that the care home did not ensure that residents' medications were kept in a safe and locked place. A civil penalty in the amount of $250 was assessed due to repeat violation. On June 16, 2026, LPA and Licensing Program Manager (LPM) Lauren Crocker conducted a visit to follow-up regarding citations previously issued at the care home.

** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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During visit, LPA and LPM observed a vial of Xylocaine in a resident's room readily accessible for a resident who should not have access to medications according to their most updated medical assessment. LPA and LPM also observed accessible medications stored in the staff bedroom. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per Section 87465(h) based on observations, which determined that the care home did not ensure to keep medications inaccessible to the residents in care when resident had a vial of Xylocaine accessible in their bedroom and medications were accessible in staff bedroom. A civil penalty in the amount of $250 was assessed due to repeat violation.

During interviews conducted by the Department, R2 indicated that they attempted to inform S1 that R1 needed to be spoon fed, in which S1 responded to R2, “Don’t tell me how to do my job.” R3 stated that, if any of the residents tried to tell S1 what needed to be done, S1 would tell them, “Don’t’ tell me how to do my job.” LPA conducted interviews with residents, including R2, R3, and R6. R2 stated that S1 would tell R2 “don’t tell me what to do” in regards to them assisting with multiple activities of daily living, including assistance with showers and cleaning. R2 stated that, if they didn’t advise S1 how to assist them, S1 would "just stand there and not do anything." R3 stated that they witnessed R2 telling S1 what to do for R1, and S1 told R2 "don't tell me how to do my job." R3 stated that they had to provide feeding assistance for R1 themselves because S1 wouldn't assist R1. R3 stated that S1 was "very disrespectful." R6 stated that care staff are violating their personal rights, including not treating the residents with dignity.

Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 only served oatmeal for breakfast and never served the residents drinks. Care Note also stated that S1 did not feed R1. “To Do List for Legacy Lane II” authored by Administrator Gaunavou and provided to S1 shows that Administrator advised S1 to provide R1 assistance with feeding for all meals from December 5, 2025 to December 9, 2025. R1’s Medical Assessment dated September 10, 2025 states that R1 is unable to feed themselves.

During interviews conducted by LPA, both R2 and R3 reiterated that S1 did not provide feeding assistance to R1. R3 stated that S1 would bring R1 out to sit at the kitchen table and put food in front of them even though they could not eat on their own. R3 stated that S1 left R1 sitting at the table, sometimes soiled. R3 stated that they had to provide feeding assistance to R1 while S1 was working at the care home because S1 wouldn’t do it.
** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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The Department conducted interviews with the residents in care and relevant parties. R2 stated that, on December 8, 2025, when S1 contacted 9-1-1 for R1 and was questioned by EMS regarding the last thing that R1 ate, S1 stated that R1 last ate “oatmeal.” R2 stated that oatmeal was what was provided to the residents for breakfast and EMS arrived during lunchtime to transport R1. R1 was transported to the hospital around 1430 hours. During interviews, multiple relevant parties reported that they witnessed R1 sitting at the dining table by themselves with food placed in front of them untouched. Multiple relevant parties acknowledged that R1 needed to be spoon fed by care staff. Relevant party stated that they visited R1 on December 8, 2026 at around 1200 hours and found R1 sitting at the dining table with their face down and oatmeal in front of them and around their mouth. Relevant party stated that R1 was unresponsive. Relevant party stated that they asked S1 what was wrong with R1, and S1 stated “I don’t know” and continued to mop the floor. Relevant party stated that they had to request S1 to contact 9-1-1.

Interviews conducted with residents R2, R3, R4, and R5 indicated that they have witnessed staff sleeping on the couch in the common areas. R2, R3, and R4 stated that they have observed S1 sleeping while on duty.

Handwritten Care Note authored by Administrator Gaunavou dated December 10, 2025 indicated that, upon returning from vacation, Administrator was notified by residents that S1 did not clean the residents’ bedrooms or bathrooms from December 5, 2025 to December 9, 2025.

The Department conducted interviews with residents R2 and R3, who stated that S1 did not do any cleaning at the care home while being the sole caregiver from December 5, 2025 to December 10, 2025.

LPA conducted interviews with residents, including R2 and R3, who stated that they saw the cleanliness of the care home deteriorate while S1 was working at the care home. R2 stated that bathroom was dirty and malodorous and towels and clothes were not laundered. R3 stated that S1 never cleaned once while working at the care home. R3 stated that bathrooms and floors were dirty while S1 worked at the care home.

** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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On June 16, 2026, LPA and LPM conducted a visit to follow-up regarding citations previously issued at the care home. During visit, LPA and LPM observed concerns regarding cleanliness and repair of the care home, including cleanliness of floors and doors, cobwebs inside the shed in the yard and in the care home, urine containers not emptied, and tarp hanging from roof. Pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency was cited per 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." This requirement was not met based on observations, which determined that the care home did not ensure the premises was clean and in good repair regarding multiple observed items addressed during visit. A plan of correction (POC) was to include the care home creating a system for cleaning the care home, addressing biowaste, and addressing repairs. Care home was also to address all concerns observed during visit. LPA cleared deficiency during a follow-up inspection. Based on the information above, the allegation that staff are not ensuring facility is clean and in good repair is determined to be substantiated. Due to care home receiving a citation for 87303(a) Maintenance and Operation during visit conducted on June 16, 2026, no additional citations for allegation will be issued.

Based on interviews conducted, observations, and records reviewed by the Department, as well as a medication count, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D pages. A civil penalty in the amount of $250 was assessed for today's date due to repeat violation. As a result of the investigation findings, an immediate civil penalty per Health and Safety Code §1569.49 in the amount of $500 for the date of July 15, 2026 is assessed for a violation that the department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

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: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Care home will complete training for all staff regarding observing residents for changes in condition and providing assistance for unmet needs. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the care home did not ensure to observe changes in R1 and provide appropriate assistance for unmet needs, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14	Care home will also provide LPA materials involved with staff training by POC due date. An immediate civil penalty in the amount of $500 is assessed for today's date due to a violation that resulted in the injury or illness of a resident in care.
Type A 07/16/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Care home will complete training for all staff regarding medication administration. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, observations, medication count, and records reviewed, the care home did not ensure to assist residents with self-administered medications as needed, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14

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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

LIC9099 (FAS) - (06/04)

Page: 8 of 12

Control Number 59-AS-20251212164744

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: 07/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2026 Section Cited CCR 87486.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Care home will complete training for all staff regarding how to treat residents with dignity. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, the care home did not ensure that residents were accorded dignity in their personal relationships with staff, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
Type A 07/16/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Care home will complete training for all staff regarding how to provide care and supervision to the residents. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the care home did not ensure to provide care, supervision, and services to meet the needs of the residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14

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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

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Control Number 59-AS-20251212164744

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: 07/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. (...) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Care home will complete training for all staff regarding personnel expectations when providing care. Care home will provide an estimated date for completion of training to LPA by POC due date of July 16, 2026. Care home will also provide LPA materials involved with staff training by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the care home did not ensure personnel were competent to provide services necessary to meet the residents' needs, which poses an immediate health, safety, and personal rights violation to the residents in care.	8 9 10 11 12 13 14	A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.
	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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

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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
12/12/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20251212164744

FACILITY NAME:	LEGACY LANE SENIOR LIVING II		FACILITY NUMBER:	345920201
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	3039 WALNUT AVE		TELEPHONE:	(564) 200-1736
CITY:	CARMICHAEL	STATE:CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	07/15/2026
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Deaja Malcolm, Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident died due to staff neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with caregiver, Deaja Malcolm, to deliver findings regarding the complaint allegation listed above. LPA spoke with Administrator, Shanice Downer, via telephone call, who gave permission for caregiver to sign report.

During investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

According to resident (R1’s) death certification, R1 died on December 16, 2025 at 1022 hours. R1’s immediate cause of death was aspiration pneumonia with leading causes of vascular dementia and cerebrovascular disease. Based on medical records, R1 was admitted to the hospital on December 8, 2025 and diagnosed with severe dehydration, starvation ketoacidosis, urinary tract infection (UTI), and right basilar atelectasis.
** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Control Number 59-AS-20251212164744

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: 07/15/2026

NARRATIVE

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On December 13, 2025, R1 was discharged from the hospital. Medical staff recommended that R1 receive hospice services at Legacy Lane Senior Living II after discharge. Based on interviews conducted by the Department, R1’s family denied hospice services but agreed to have R1 placed on oxygen. According to R1’s family, R1 had been declining medically since around October 2025, was losing weight, and needed to be spoon fed their meals.

Sacramento County Sheriff’s Office detective interviewed R1’s primary care physician, who reported that R1’s family did not report any medical concerns related to R1’s decline but knew that R1 needed to be spoon fed. R1’s primary care physician noted that R1 was diagnosed with dementia and was admitted to the care home for acute renal failure. R1 did not require a special diet. Based on the findings written above, the allegation that R1 died due to staff neglect is unsubstantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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: 07/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026

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