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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701615
Report Date: 06/16/2026
Date Signed: 06/16/2026 03:45:43 PM

Document Has Been Signed on 06/16/2026 03:45 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY LANE SENIOR LIVING IIIFACILITY NUMBER:
342701615
ADMINISTRATOR/
DIRECTOR:		GAUNAVOU, MORIAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(564) 200-1736
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
06/16/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Esther Tabua, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On June 15, 2026, Licensing Program Analysts, Reza Jamaly (LPA) and Arvin Villanueva (LPA), arrived unannounced at this facility conduct a case management visit. LPA initially met with staff on duty, Kirk Campbell (S1), and stated the purpose of the visit. The administrator assistant, Esther Tabua (S2), was notified and arrived later during the visit.
This visit is being conducted concurrently with a complaint investigation (Complaint 27-AS-20260610160204).
During this visit, LPAs conducted facility observation.
  • LPAs observed the fire door, located at the kitchen area, was propped open by a door stopper (photo taken).
  • Room temperature was at 86 degrees Fahrenheit. LPAs observed electric fans were being utilized during this visit. LPAs observed resident rooms to have electric fans on. The living room and kitchen area - LPAs observed electric fans being utilized. Per interview with S2, the air conditioner stopped working. Per S2 she called for maintenance person on Sunday, June 14, 2026, to come assess but was unable to fix. Another maintenance person will arrive this Thursday, June 18, 2026. S2 stated she ordered 7 electric fans for the facility to use. Some rooms have ceiling fans.
  • Inside the refrigerator, LPAs observed 2 Ensures (photo taken). These Ensures are accessible to residents in care. Per review of 6 of 6 resident Medical Assessments (LIC602), at least one resident was assessed to be at risk if they have access to nutritional supplements.
Based on today's visit, the facility is hereby cited and also assessed a civil penalty of $1000 due to a repeat violation.
Plan of corrections and appeal rights were discussed with S2 during exit interview. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2026
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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Document Has Been Signed on 06/16/2026 03:45 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 06/16/2026 at 02:52 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 III
FACILITY NUMBER: 342701615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2026
Section Cited
CCR
87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Administrator assistant closed the fire door upon her arrival to the facility.
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Based on observation, LPA observed, upon arrival to the facility, 1 of 2 fire doors were propped open with door stoppers. This poses an immediate health, safety, and personal rights risks to persons in care.
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Per discussion, the administrator assistant agreed to submit a staff training regarding fire safety, including those related to fire doors.
Submit proof of training by 6/23/2026.
Type B
06/23/2026
Section Cited
CCR87309(c)

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the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.
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Staff removed the Ensures from the refirgerator and placed them in a locked cabinet.
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This requirement is not met as evidenced by:
LPAs observed 2 bottles of Ensures inside the kitchen refrigerator; per record review, at least one resident in care are at risk if they have access to nutritional supplements. This pose a potential health, safety, and personal rights risks to persons in care.
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Per discussion, the administrator assistant agreed to submit a staff training regarding the regulation cited.
Submit proof of training by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
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