342702896-4-30-2026-27-AS-SRIN-DURTLT-20260605145002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 04/30/2026
Date Signed: 04/30/2026 03:59:50 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
09/25/2025 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20250925104337

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	JONATHAN AGUILAR		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 78	DATE:	04/30/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Donnabell Galicia		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable Death
Resident fell multiple times due to staff neglect
Staff dropped resident resulting in injuries
Staff make inappropriate comments towards residents
Staff don't treat residents with dignity
Staff did not ensure facility was free of pests
Staff do not have proper supplies for resident's hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a complaint investigation and deliver complaint findings. LPA Valerio met with current administrator Donnabell Galicia, and explained the purpose of the visit.

The following has been determined as it relates to the following allegations:

Allegation: Questionable Death

This allegation was investigated under complaint #27-AS-20250522140000. The complaint finding was determined to be unsubstantiated.

Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250925104337

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: 04/30/2026

NARRATIVE

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...Continued from LIC 9099 -C, page 2
LPA Valerio was provided monthly pest control services for September, October, November and December of 2025. Reports indicate that the facility had regular check ups every other Tuesday of the month. There were reports that showed that they also came additional times. They have bait traps throughout the facility. During one of the visits on 09/02/2025, there were 12 bait traps, 9 of which had activity in the traps. Other inspections indicated that the services for pesticides were put on the outside of the facility

Allegation: Staff do not have proper supplies for resident's hygiene needs

According to the RP, the facility does not have wipes for the residents during changes and staff must use paper towels.

LPA Valerio conducted an unannounced visit on February 03,2026. During the visit, LPA Valerio observed multiple closet areas located in the facility that stored hygiene supplies (briefs, shampoo, condition, shaving cream, hand soap, hand sanitizer, toothpaste, body lotion, body wipes etc.). According to an interview with the previous administrator Johnathan, the facility always has a stock of hygiene supplies for the residents.

On April 30, 2025 LPA Valerio interviewed Staff 5 (S5). S5 is one of the few staff members that are still employed from before any management changes. S5 stated the facility has had wipes in stocked. S5 showed LPA were they would have kept them.

Based on all the information collected by the Department, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred, therefore the allegations are UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility with Administrator Donnabell Galicia.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250925104337

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: 04/30/2026

NARRATIVE

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Allegation: Resident fell multiple times due to staff neglect

According to the Reporting Party (RP), Resident 1 (R1) fell multiple times. LPA Valerio requested incident reports for September and October of 2025. According to the records submitted, R1 did not have any incidents for October of 2025. In September, R1 had an unwitnessed fall on September 24, 2025. Alpha one was contacted by staff to assist the resident back up. R1 did not want to go to the emergency room.

Allegation: Staff dropped resident resulting in injuries

According to the RP, Resident 2 (R2) was dropped by Staff 1 (S1). RP reported that R1's toes on the right foot were scraped, left hand hurting, and had a bruise on the left leg. According to records submitted to LPA Valerio, R2 did not have any incident reports for October of 2025. LPA Valerio interviewed S1. According to S1, S1 did not provide direct care to any of the residents. S1 stated S1 was rarely in the community. R2 could not be interviewed due to no longer living in the community.

Allegation: Staff make inappropriate comments towards residents/ Staff don't treat residents with dignity

According to the RP, Staff 2 (S2), rude to the residents, doesn’t let them speak about concerns, talks to them like they’re dumb, makes them cry, and has no empathy for them. According to an interview with Staff 3 (S3), S2 is not rude. S3 believes "it is a language barrier and cultural thing that people find different. S3 is very loud but that is how S2 talks."According to an interview with Staff 4 (S4), S4 reported S2 being loud and has an accent but is super nice.LPA Valerio attempted to interview S2; however, S2 does not work at the facility and the last contact information is invalid.

Allegation: Staff did not ensure facility was free of pests

LPA Moleski conducted an unannounced visit on September 26, 2025. LPA Moleski did not indicate the observation of any pest in the community. On February 03,2026, LPA Valerio did not observe any pest in the community at the time of the visit. During this visit, LPA Valerio observed a pest control maintenance man at the facility conducting his quarterly visit.

Continues on LIC 9099 - C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC9099 (FAS) - (06/04)

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