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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920201
Report Date: 09/15/2026
Date Signed: 09/15/2026 03:59:37 PM

Document Has Been Signed on 09/15/2026 03:59 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY LANE SENIOR LIVING IIFACILITY NUMBER:
345920201
ADMINISTRATOR/
DIRECTOR:		DOWNER, SHANICEFACILITY TYPE:
740
ADDRESS:3039 WALNUT AVETELEPHONE:
(916) 664-3914
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
09/15/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Deaja Malcolm, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Caregiver, Deaja Malcolm, to obtain a signature relative to amending a report for an inspection conducted on July 15, 2026. Signature was obtained for amended document during visit.

During visit, LPA toured the premises and observed multiple items in disrepair, including downspout detached from roof gutter and side gate in disrepair. LPA observed microwave to be unsanitary in kitchen area. LPA also observed trash and debris on the side of the house. LPA observed one (1) black widow on the premises in resident (R2's) bedroom. LPA conducted interviews with residents (R3 and R4) who stated that they have also observed spiders in their rooms and have had to kill the spiders themselves.

During visit, LPA observed resident (R1) request PRN medication that was missing from the premises. LPA reviewed R1's medications on site and observed two (2) medications that were identified on R1's medication list but missing from the premises (Hydroxyzine and Varenicline). LPA reviewed R1's Medical Assessment dated March 12, 2026 and observed that R1 is unable to administer their own prescription medications and unable to store their own medications. LPA reviewed R1's Centrally Stored Medication Form (CSMF) and observed R1's last bottle of Varenicline was filled on April 21, 2026 with 56 tabs and R1's last bottle of Hydroxyzine was filled on May 2, 2026 with 60 tabs. R1's Medication Administration Record (MAR) does not show any tabs of Hydroxyzine being administered for R1. R1's MAR shows 62 tabs given of Varenicline for July 2026 and 56 tabs given for August 2026, ending on August 29, 2026, despite only one (1) bottle of 56 tabs being documented on R1's CSMF. LPA did not observe any evidence on site that R1's Varenicline was refilled or discontinued.

** Report continued on 9099-C **
Anthony Perez
Michael Hood
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY LANE SENIOR LIVING II
FACILITY NUMBER: 345920201
VISIT DATE: 09/15/2026
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As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Two (2) civil penalties in the amount of $250 were assessed for today's date due to repeat violations. Deficiencies are listed on 809-D pages.

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

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2026 03:59 PM - It Cannot Be Edited


Created By: Michael Hood On 09/15/2026 at 03:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87465(a)(4)

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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:
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Care home will create a plan on how they will ensure that medications are refilled and maintained on site, and documentation for medications is maintained and accurate. Care home will submit plan to LPA by POC due date of September 16, 2026.
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Based on LPA's observations and records reviewed, the facility did not ensure that residents were receiving medications as prescribed as two (2) medications for R1 were missing from the premises, which poses an immediate health, safety, and personal rights risk to residents in care.
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A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.
Type B
10/05/2026
Section Cited
CCR87303(a)

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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. This requirement is not met as evidenced by:
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Care home will increase pest control services as needed to address infestation. Care home will also address all concerns observed during visit. LPA will conduct a future visit to clear deficiency.
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Based on observations, the care home did not ensure the premises was clean and in good repair in multiple areas of the care home, and did not ensure the premises was free of pests, which poses a potential health, safety, and personal rights risk to the residents in care.
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A civil penalty in the amount of $250 was assessed for today's date due to repeat violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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