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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920201
Report Date: 10/24/2025
Date Signed: 10/24/2025 02:19:07 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
07/09/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250709144213
FACILITY NAME:LEGACY LANE SENIOR LIVING IIFACILITY NUMBER:
345920201
ADMINISTRATOR:GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:3039 WALNUT AVETELEPHONE:
(564) 200-1736
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/24/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Moria Gaunavou, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not ensuring that residents are treated with dignity and respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Moria Gaunavou, to deliver findings regarding the complaint allegation listed above.

During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are not ensuring that residents are treated with dignity and respect

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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 3
Control Number 59-AS-20250709144213
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: 10/24/2025
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
Interview conducted with R1 indicated that they are being disrespected by residents and care staff at the care home. R1 stated that they have been called names, such as an "old hag," by resident (R2). Resident stated that they were grabbed by R2 on the arm along with care staff (S1). R1 stated that R2 and S1 tried to force R1 into their room. R1 stated that R2 and S1 were unsuccessful in forcing them back into their room after resisting. R1 stated that they contacted local law enforcement regarding the incident.

R2 denied physically assaulting R1 during incident on June 6, 2025. R2 denied anyone, resident or staff, assaulting R1 on June 6, 2025. R2 stated that they did have a verbal altercation with R1 on June 6, 2025, including getting in R1's face and telling R1 to go to their room. R2 claimed that R1 has violated their personal rights on multiple occasions. Interview with resident (R3) and Administrator confirmed that there have been verbal altercations between R1 and R2 at the facility. R3 stated that R1 and R2 have yelled at each other, but have never physically assaulted each other. R3 stated that they witnessed incident on June 6, 2025, and stated that neither R2, nor S1, physically assaulted R1. R3 confirmed that R1 tends to violate other residents' personal rights. Administrator stated that they did not witness incident on June 6, 2025. Administrator stated that R1 tends to start conflict with the other residents. Administrator will redirect residents when they initiate verbal altercations between each other.

LPA contacted local law enforcement for records and information regarding incident on June 6, 2025. LPA spoke with local law enforcement representative via telephone call, who stated that no police report was completed regarding incident. Local law enforcement representative stated that there was a "disturbance" at the facility on June 6, 2025, but no crime was found to be committed. Local law enforcement representative stated that caregiver on site did not witness any physical altercation between residents on June 6, 2025. LPA reviewed R1's Admission Agreement, including house policies. LPA did not observe any house policies established in admission agreement regarding personal rights and residents treating others with dignity and respect.

Based on interviews conducted 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 was 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: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250709144213
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: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2025
Section Cited
CCR
87468.1(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
Facility will update house policies for all residents to include personal rights violations. Facility will have all residents sign house policies to include in their admission agreements. Facility will submit updated and signed house policies to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, the facility did not ensure that residents were treated with dignity and respect in their relationships with other residents, which poses a potential health, safety, and personal rights 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.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3