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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 02/09/2026
Date Signed: 02/09/2026 04:18:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
05/22/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250522140000
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 85DATE:
02/09/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jonathan Aguilar, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Questionable death.
INVESTIGATION FINDINGS:
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On 02/09/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Jonathan Aguilar and Rosaliee Sullivan the incoming ED.The three reviewed the report below.

Regarding: Questionable death of a resident.

A review of the resident’s (R1’s) medical records and death certificate was conducted as part of this investigation. R1 passed on 05/04/25 at their care facility. R1’s death certificate indicated Alzheimer’s as the immediate cause of death. Other significant conditions that were listed on the death certificate and contributed to their death were Parkinson’s disease and chronic pulmonary disease.

No signs of a suspicious death were noted or listed on R1’s death certificate. An autopsy was not
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
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 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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requested and law enforcement did not investigate.

LPA reviewed 16 incident reports dated 12/21/24 – 05/04/25 sent to community care licensing. 5 of these reports described incidents where R1 told staff they fell and hit their head, or staff found the resident on the floor with a head wound. R1 was sent out for evaluation each time. 8 reports described R1 having a change of condition.

An additional 3 reports, dated 08/02/24, 10/18/24 and 03/17/25, described medications that were not administered to R1. The report dated 08/02/24 stated that "the resident was experiencing a change of condition related to missing their medications. The MD appointment was not scheduled until September 2024; and there were no other satellite clinic appointments available. The resident was sent to the … hospital in attempt to get emergency refills for all medications to hold until the next in-person appointment in September." The report dated 10/18/24 described 10 medications that were missed for two or more days from October: 10/01/24 - 10/25/24 (25 days). The report dated 3/17/25 also stated that R1 missed doses on 2 days because the facility did not have them in stock.

LPA will be following up with a case management to address R1’s repeated falls and head injuries. LPA will also address Licensee’s not ensuring that R1’s medications were in stock for administration.

Regarding: Questionable death of a resident.

The Department found the allegation, questionable death of a resident (R1) to be UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

According to the California Code of Regulations, Title 22, no deficiencies were observed during today's visit. A copy of this report was provided and an exit interview was conducted with Aguilar.

Another visit was conducted immediately following this one to address the other allegations that were a part of this complaint.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
05/22/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250522140000

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 85DATE:
02/09/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jonathan Aguilar, Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are coercing residents into using the facilities hospice company.
Staff are threatening residents.
Staff did not safeguard residents personal belongings.
Staff are not adequately supervising residents at night.
Staff are not following residents care plans.
Staff handled resident in a rough manner.




INVESTIGATION FINDINGS:
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On 02/09/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Jonathan Aguilar and the two reviewed the report below.

Regarding: Staff are coercing residents into using the facility's hospice company.

During an interview with a staff member (S11) on 8/21/25, S11 confirmed that the Licensee owned the hospice agency referred to as Medical One and that staff were instructed to promote it.
This LPA obtained a list of all the residents receiving hospice services during the time this complaint was initiated. The document provided listed 3 residents receiving hospice services from Medical One and 7 residents receiving services from other agencies. LPA phoned the Power of Attorney / emergency contact or
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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responsible party (RP) for the 11 residents listed and interviewed those for R2 - R8. This LPA learned the following:

The RP for R2 stated R2 had been utilizing a home health agency that had their own hospice agency and transitioned to that when hospice services were required. They stated that they “had a positive experience with Legacy Oaks.”

The RP for R3 stated that Legacy Oaks "didn't offer us any options - they put R3 on hospice with Medical One without telling any of us. They apologized and said they were wrong and that they should have notified us." There was no notice of a change of condition, discussion about a reappraisal, and additional hospice options were not provided.

The RP for R4 stated that when it became clear that hospice services were needed, "Legacy Oaks said they had an agency and gave me their card. No other hospice options were provided. The RP for R4 stated, "A very nice young lady spent hours evaluating R4 but then they said R4 was not accepted to their program. Another agency called us the next day and they took R4."

The RP for R5 stated that they received a phone call from a representative at Legacy Oaks. The RP stated that this representative called and told them. “R5 is now on Medical One Hospice, did you know that?” The RP stated that they were not notified of any change of condition that would require hospice services and they were not offered any other options.

The RP for R6 stated that a staff person (S10) recommended Medical One, no other options were provided. The RP explained that R6 did not renew their medical insurance and was dropped by their carrier. Since they could not pay, Medical One discontinued providing services to R6. Another hospice agency picked R6 up. The new agency was the one listed on the document provided to this LPA as they were the agency actively serving this resident at the time of this complaint; however, they started with Medical One.


Regarding: Staff are coercing residents into using the facility's hospice company.

The RPs for 4 different residents stated that they were not provided options for hospice services other than Medical One. The preponderance of the evidence standard has been met and the department finds the above allegation SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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Regarding: Staff are threatening residents.
Regarding: Staff did not safeguard residents personal belongings.

LPA learned through this investigation that resident 6, (R6) had snacks stored in their room that staff, (S9) would help themselves to during their shift. In an interview with S16, this LPA was told that R6 went to S16 crying and afraid because S9 told R6 that they would end up in Memory care. S16 asked why R9 thought they were going to memory care. R6 told them that “S9 told R6 to stop complaining to Management about them - no one was going to believe them and they were going to put R6 in memory care.” S16 brought this information to the ED who said that they would take over the investigation. The ED, Aguilar, stated that an investigation was conducted into the matter and said that they confirmed that S9 had been bullying R6 and taking their snacks. As a result of that investigation, combined with other previous offenses, S9 was terminated.



This LPA also learned through interviews with S12, S16, and R6 that weeks went by before S9 was prevented from taking R6's personal property. LPA asked how long, R6 responded weeks, but I don't know how many. S12 stated that at the time there were a few employees suspected of stealing from residents. S9 was one of them. Another resident, (R8) told S12 that they woke up once and saw S9 going through their things when they had no reason to be in R8's room. S12 stated that they knew management had been informed of the situation by S16, but nothing was done about it for weeks. "It was even brought up in stand-up."

LPA Viarella interviewed S6 and asked what happened when they went to management regarding S9 taking their food and threatening them. R6 said at first they said they would look into it, but nothing happened. S9 kept doing it. Then they reassigned S9 so they wouldn't even a reason to come to my room, but S9 still came and told me to stop complaining. Eventually it stopped but it took a while. LPA asked which members of management R6 spoke with and R6 said they didn't want to talk about it anymore, they were just glad it stopped.

Regarding: Staff are threatening residents.
Regarding: Staff did not safeguard residents personal belongings.

The standard for the preponderance of evidence has been met and the department found the above allegations to be SUBSTANTIATED. These deficiencies have been cited on the LIC 9099D page.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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Regarding: Staff are not adequately supervising residents at night.

This LPA interviewed the Designated Facility Administrator / Executive Director (ED) Jonathan Aguilar, regarding company policy. Aguilar stated that staff were to be "awake during their shifts and at no time sleeping on the sofas throughout the building." LPA observed that the Plan of Operation had a section titled "Awake Night Staff: Staff members were scheduled to be alert and on-duty during overnight hours to monitor and support residents requiring nighttime supervision."

This LPA conducted 5 interviews, 2 residents and 3 staff R4, R7, S3, S4 and S5. R4 stated they had seen staff sleeping on the sofas in the hallways of the assisted living area. LPA stated that this complaint was opened on 05/22/25 and asked if this was occurring back then as well. R4 said yes. "Some of the staff that used to do it a lot aren't here anymore, but it still happens sometimes, not as much as it used to, but I have seen it." R7 also stated that they had seen staff sleeping on the sofas during the overnight shift too.

S5 stated they had seen staff sleeping on the sofas in both the assisted living area and memory care. S4 and S5 stated that S6 had 2 disciplinary warnings for sleeping while on duty. LPA asked the ED for a copy of S6's personnel file. The ED was unable to locate it; however, he was able to provide this LPA with a copy of the second warning dated 11/10/25. It stated, "The employee was observed sleeping during their scheduled shift."

Regarding: Staff are not adequately supervising residents at night.

2 residents and 3 staff stated that staff have been seen sleeping during their shifts. The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

Regarding: Staff are not following residents care plans.



When S5 was asked if care plans were being followed, S5 stated that, that "Residents are not getting the showers they are supposed to. S5 stated that when they get a refusal, they change their approach or do a change of face. Others don't bother. There are some refusals, but some caregivers are just lazy." While reviewing personnel files, this LPA observed that 4 staff members (S20-S24) received disciplinary warning notices on 10/24/25. The warnings were for not documenting “the resident’s refusal to participate in the scheduled shower on (dates listed were 10/24/25, 10/11/25, 09/06/25, 09/13/25
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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Based on a document review, MedTech, S7 did not complete any annual MedTech training in 2025 and only 2 hours of dementia care training. LPA reviewed the personnel file for S7 and found that on 10/12/25 S7 stated, “I was giving four people meds at the same time.” S7 gave a medication (Atorvastatin 40mg) intended for resident (R9) to resident (R10). LPA also reviewed a 30-Day Performance Improvement Plan (PIP) for S7 with a start date of 12/03/25. It stated “The employee failed to consistently follow established protocols for ordering, tracking, and verifying medications This appears to be caused by a lack of adherence to procedure and inconsistent follow-up on assigned responsibilities. The employee did not consistently communicate or follow-up with physicians (MD) and responsible parties (RP) regarding medication issues in a timely manner. This was due to inadequate prioritization of critical communications and insufficient attention to follow-up requirements. The employee failed to submit an incident report for a missing medication as required by company policy and regulatory standards. This was caused by neglect of reporting responsibilities and failure to recognize the critical importance of documentation for compliance and resident safety.” There was a sheet for S7’s supervisor to list “Goal” and to provide “Status and Comments” along with dates for progress checking. They were listed: 12/10/25, 12/17/25, 12/24/25 and 01/03/26. None were filled out.

Regarding: Staff are not following resident care plans.
The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

Regarding: Staff handled resident in a rough manner.

LPA interviewed 2 staff S5 and S16 regarding a particular incident that took place in memory care where it was alleged that a third staff member, S7 roughly handled a resident. Due to the cognitive impairments of the 2 residents involved, neither were considered credible witnesses to interview. S16 stated they saw S7 put their hands on R10 and pushed them down onto the sofa in memory care all the while screaming at R10. S16 said that R10 had curled up on their side in a fetal position and was visibly frightened. S5 stated they did see S6 get between R10 and R5. S5 stated that R10 was grabbing at R5 and S6 stepped between them and told R5 to sit down. S6 did put their hands on R10 and pushed them down onto the sofa.

Regarding: Staff handled resident in a rough manner.


The standard for the preponderance of evidence has been met and the department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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respectively) was not documents in either the Shower Refusal Form, the Shower Sheet, or ALIS (the computer system). This omission represents a lapse in required documentation and poses a potential compliance risk with care plan protocols and regulatory standards.” All 4 staff members signed an acknowledgement of warning.

During the course of this investigation, this LPA also learned from Ashley Sylve and Jonathan Aguilar that the facility went from 3 MedTechs per shift to 2. S5 stated that "the most important way they are not following them (care plans) has to do with medications. They do meds in assisted living before memory care. Some of our residents are suppose to get their first meds and 7:00 AM (before breakfast) and they aren't getting them until 11:00 AM and that messes up the second pass because it's too soon. They aren't following the doctor's orders and it has gotten worse since we have gone down to 2 MedTechs." While reviewing personnel files for MedTechs, this LPA found a Counseling Documentation Form for S7 dated 01/08 25. The first page of the document included the following:

“Level of Corrective Action – Final Warning. Nature of Violation – Policy or Safety Violation.
Incident Summary: It has been observed and documented that multiple medication technicians have failed to consistently follow established policies and procedures regarding medication management. The following areas of concern have been identified:

1. Documentation Errors: Instances of incomplete, inaccurate or later entries in the EMAR system.


2. Medication Handling: Failure to adhere to proper medication storage, distribution, and disposal protocols.
3. Communication Failures: Instances where medication discrepancies or issues were not promptly reported to supervisors or healthcare providers as required.”

“Goals /Corrective Actions” were then listed along with sections for S7 to offer an explanation or rebuttal. These sections were blank. The form was then signed by S7, their supervisor and dated 01/08/25.
Because the form stated that “multiple medication technicians had failed to consistently follow established procedures regarding medication management,” this LPA contacted the current Executive Director (ED), Jonathan Aguilar for clarification. Aguilar stated that it was his first day at Legacy Oaks and was completing his on boarding, but that the ED at the time, Ashley Sylve, had written up all 12-14 medication technicians as they all had not been following proper procedures and protocols. Aguilar stated that “the meeting was 2-3 hours long and that the MedTechs all participated in a refresher training session.”
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 02/09/2026
NARRATIVE
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According to the California Code of Regulations, Title 22, no other deficiencies were observed during today's visit. Due to time constraints, a case management will be conducted at a later date to address the additional deficiencies observed during this investigation.

A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Aguilar.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2026
Section Cited
CCR
87468.2(a)(7)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents...(7) To fully participate in planning their care... and services to be provided... The licensee shall provide necessary information..
The Licensee did not meet this requirement as evidence by:
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The facility stated they will conduct a training with managers regarding this regulation today. By close of business tomorrow an attestation will be signed by all managers that will include the regulation and their understanding of it. This will be emailed to CCLASCPSacramentoSouthRO@dss.ca.gov
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Based on interview and record review, the RPs for 4 different residents stated that they were not provided options for hospice services other than Medical One. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.
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and a copy to Stephen.Richardson@dss.ca.gov by COB 02/10/26

Sullivan also stated that this regulation will be included in the all staff and emphasized that at least 3 hospice options will be provided.
Type A
02/10/2026
Section Cited
CCR
87468.2(a)(8)
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7
(a)In addition to the rights listed in Section 87468.1, Personal Rights of...(8) To be free from neglect, financial exploitation... punishment, humiliation, intimidation, and verbal, mental, ...
The Licensee did not meet this requirement as evidence by:
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7
Facility will be supplying CCL with the name of an outside trainer (Ombudsman or Hospice)and the date that they will collaborate on to conduct an in-service on Personal Rights and Abuse. This will be submitting by the COB 02/10/26
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9
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Based on interviews with R6, S12, S16 and the ED, S9 was threatening R6. This posed/poses an immediate risk to the health, safety, and/or personal rights of 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: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 10 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2026
Section Cited
CCR
874682.2(25)
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7
(a)In addition to the rights listed in Section 87468.1...(25) To protection of their property from theft or loss according to Health and Safety Code sections...

The Licensee did not meet this requirement as evidence by:
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Facility will submit a plan to conductedt a training for all staff on the theft and loss policy and how theft and loss are related to residents personal rights. This plan will be submitting by the COB 02/10/26 and signature sheets will be submittied when the training is completed.
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Based on interviews with R6, S12, S16 and the ED, S9 was taking food from R6's room. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.
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Type A
02/10/2026
Section Cited
CCR
87411(a)
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7
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.…
The Licensee did not meet this requirement as evidence by:
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7
Facility will submit a plan for unannounced check-ins after hours to ensure that staff are awake and alert as required. This plan will be submitted by the COB of 02/09/26 to CCL.
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Based on interviews, 2 residents and 3 staff (R4, R7, S3, S4 and S5) stated that staff have been seen sleeping during their shifts.

This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.
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9
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 11 of 12
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2026
Section Cited
CCR
87465(a)(4)
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3
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5
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7
(a) A plan for incidental medical and dental care shall be developed ...(4) The licensee shall assist residents with self administered medications as needed.
The Licensee did not meet this requirement as evidence by:
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7
The facility has contracted with a pharmacy to obtain a 10-day emergency supply of medications when necessary to prevent residents from missing prescribed meds. Facility will supply documentation regarding this new agreement/procedure. This will be done by COB 02/09/26.
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Based on interviews with the ED and S5 and a record review of S7's personnel files, the licensee did not ensure that staff assisted residents with self administered medications as needed per their care plans. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.
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14
Type A
02/10/2026
Section Cited
CCR
1569.626(a)
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7
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:

The Licensee did not meet this requirement as evidence by:
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3
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5
6
7
Facility will submit updated audit of annual dementia care training to CCL and a timeline for completion by COB, 02/09/26.
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Based on record review S7 only had 2 hours of dementia care training and had not completed the required number. This posed/poses an immediate risk to the health, safety, and/or personal rights of residents in care.
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9
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 12 of 12