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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 04/29/2026
Date Signed: 04/29/2026 03:19:17 PM

Unfounded


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
09/10/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250910090018
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 78DATE:
04/29/2026
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Donnabell Galicia, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility refused to accept resident after being discharged from the hospital.
INVESTIGATION FINDINGS:
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On 04/29/26 Licensing Program Analyst (LPA) Kimberly VIarella made an unannounced visit to this facility to complete and deliver the findings for the investigation into the above allegation. LPA announced herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with the new Executive Director (ED) Donnabell Galicia and a brief interview followed.

The ED stated they had been at the facility for about 1 week and that they were looking forward to making improvements. This LPA inquired if they had submitted all of the paperwork for a change of administrator and the ED stated the Licensee was working on submitting the packet. LPA provided the ED with the list of the documents required.

During this visit this LPA observed, 1 staff member in the lobby area answering phones and greeting people, 1 medication technician administering medications, 2 housekeepers servicing rooms, 1
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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 3
Control Number 27-AS-20250910090018
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: 04/29/2026
NARRATIVE
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medication technician in the medication room as seen through the open door, activities staff preparing for a resident program, and 1 care staff assisting a resident with a concern in their room. LPA also observed residents chatting with members of the new management team, signing up for excursions in the log in the large common room, and one resident sitting in the lobby.

Regarding the above allegation: Facility refused to accept resident after being discharged from the hospital:

Based on interviews conducted with the resident (R1), Marlene Bremmer, the Interim Executive Director, and Ashley Sylve, Quality Assurance/Performance Improvement Director (RQAPID)/Designee, this LPA learned the following. On 08/22/25, R1 went to the hospital for medical treatment of a wound. While there, R1 was also diagnosed with a contagious infection and they remained at the hospital for further treatment. On 08/28/25, R1 returned to the facility from the hospital without having been re-assessed at the hospital by a member of the facility. This LPA also learned from an interview with Bremmer, that the hospital contacted Legacy Oaks to let them know that R1 had left without completing their discharge process. During that conversation, Bremmer learned from the hospital representative that R1 had identified themselves as living independently. Bremmer clarified and stated that although R1 was an independent person, R1 resided in an assisted living facility. At the time of this complaint, the census was 84 residents in care.

When R1 arrived at the facility, Bremmer refused to allow R1 to stay without returning to the hospital to be reassessed. Bremmer stated, "Whenever a resident is in the hospital for 3 or more days, we always reassess their care needs in case their care plans need to be updated." Bremmer went on to say that the facility had to have the correct documentation from the hospital to establish that R1's medical condition was not a risk to other residents along with what steps the facility needed to put into place to continue to care for R1's wound. Bremmer stated, "We were not trying to evict R1, we were enforcing our infection control protocols."

This LPA learned from R1 there was, "No reason they should have made me return to the hospital to wait in the ER waiting room until I could be seen again or until the facility could send someone to reassess me and allow me back." Instead, R1 told this LPA that, "I stayed at my girlfriend's house and the next day I went to my doctor." The following day R1's primary care physician cleared R1 to return to the community. R1 presented their documentation to Bremmer and arranged for home health to continue the wound care.

The facility did not evict R1; it delayed R1's readmission back into the community until they could provide
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250910090018
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: 04/29/2026
NARRATIVE
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proper medical clearance. This process took less than 24 hours. The Department found the allegation, " "Facility refused to accept resident after being discharged from the hospital," to be UNFOUNDED.

A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's visit. A copy of this report was provided and an exit interview was conduced with Galicia
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3