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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 05/12/2026
Date Signed: 05/12/2026 05:19:00 PM

Substantiated


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 SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 81DATE:
05/12/2026
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Donnabell GaliciaTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications
Facility is in financial distress
Staff inappropriately moved residents to other rooms for staff use of those rooms
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 Administrator Donnabell, and explained the purpose of the visit.

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

Allegation: Staff are mismanaging resident's medications

LPA Valerio requested three (3) resident files from previous interim administrator Rosalie Sullivan. LPA Valerio received and reviewed Medication Administration Records for Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). R1 did not receive a medication on October 29, 2025.

Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
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 6
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: 05/12/2026
NARRATIVE
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Continued from LIC 9099

There were no notes on the MAR to indicate the reason for the missed medication dose on the records provided to LPA Valerio. On October 1, 2025, R2 did not receive their dose of "Flucticasone Prop spray" due to the medication not being available in the community." R3 had an order for Alendronate sodium. The order is to take 1 Tab by mouth every week. According to the MAR, facility staff indicated that the medication was not available on October 23, 2025 and October 30, 2025. R3 also had an order for Vitamin D3, which was not given on October 5, 2025 because the facility did not have it available.

On April 30, 2026, LPA Valerio received an Unusual Incident Report (UIR) for Resident 4 (R4). According to the UIR, R4 was provided a medication that was for another resident; however, the medication was not fully ingested. R4 was sent out and returned to the community the same day with a discharge diagnosis of "worried well".

Allegation: Facility is in financial distress
The solvency audit was conducted by Audit Investigator Banahene. According to the The September 2025 sample month Profit & Loss statement, the facility did not generate any revenues and had a net loss. The licensee did not provide any document to show that the facility’s rent or mortgage was paid and that the licensee has good control over the facility. The review of the six-month utility billings showed that the licensee made full payments for PG&E, Comcast, Waste Management, Pest Control, Consolidated Utilities. However, the licensee did not make any payment for SMUD in April 2025 and made only partial payments in May, August, September 2025 and carried unpaid balance as high as $25,708. Additionally, the records show that the licensee had a lot of significant monthly financial obligations (loans and credits cards), which creates some financial concern due to the facility not generating income or sufficient income to cover expenses. Additionally, a working capital analysis was performed and the licensee had a negative working capital for the Sample Month September 2025. A negative working capital indicates that the company doesn’t have enough current assets to cover its short-term obligations and may have trouble paying suppliers and creditors and difficulty raising fund. The bank statements provided showed positive balances, however, the positive balances were significantly below the estimated monthly expenses for the facility with 160 beds. Moreover, it appears the licensee does not have sufficient cash reserves to cover the operating cost.

Continues on LIC 9099 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 05/12/2026
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Allegation: Staff inappropriately moved residents to other rooms for staff use of those rooms

On 02/03/2026, LPA Valerio was told by previous Administrator Johnathan Aguilar that as far as he knew, the residents should have been informed. All residents were moved due to renovations and maintenance and would be moved back after it was done.

On 02/03/2026 , Staff 1 (S1) informed LPA Valerio that residents were given notice. S1 remembers the paper and an email that was sent from management.

LPA did not receive a copy of the notice that was provided to the residents.

LPA Valerio reviewed resident council meeting notes dated October 2,2025. Resident Council Meeting notes are written by the residents and submitted the executive director for review. According to the meeting notes, residents wrote the following: "Confusion reigns! Everyone is confused about the abrupt changes with NO notification. Some people woke up on Monday being told they were moving that day. People were thrown together with no consideration about compatibility. We are repeatedly told that you work for us, but this is a prime example of that not being true. What is going on? Residents are upset over the way the changes were handled so abruptly without notification. Management says they posted flyers; but they were posted after the moving had begun; people don't go down the halls reading what's on the walls. It would have been better had they given notices to each resident effected. Prior to the flyers being posted, people were just moved to different areas without notice. It was upsetting."

According to an interview with Resident 4 (R4), the previous management were moving people abruptly without notice. They posted it on the wall but we don’t look at wall. They said the room was a problem but they never did the work.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a).…(4)The licensee shall assist residents with self administered medications as needed…This requirement was not met as evidenced by:
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Licensee stated the Regional Nurse, Carolyn, will be retraining the staff on all Medication related topics effective 05/12/2026. LPA Valerio to receive by the POC due date the in-service training provided today and what topics will be covered in the upcoming weeks.
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Based on record reviewed, the facility did not ensure that R1, R2, R3, and R4 was assisted with receiving their medications, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
05/13/2026
Section Cited
CCR
87405(d)(3)
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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).... (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by:
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Licensee stated they have implemented weekly financial reviews (Rent, Staff, Budget) with the Administrator. LPA Valerio to receive a copy of their standard operating procedure by POC due date,
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Based on the solvency audit, the licensee did not ensure to maintain or supervise the maintenance of financial or other records, which poses an immediate health, safety, and personal rights risk to 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: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2026
Section Cited
CCR
87205
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87205 Accountability of Licensee Governing Body (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by:
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Licensee stated they have implemented checklists that will be submitted to the Licensee moving forward, which according to the licensee, allows them to be more involved and aware of daily operations. LPA Valerio to receive a copy of policy and procedure by POC due date.
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Based on records review and interviews, the licensee did not take accountability for past due balances for the facility, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
05/13/2026
Section Cited
CCR
87213
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87213 Finances Finance The licensee shall have a financial plan.. and that assures sufficient resources to meet operating costs for care of residents... This requirement was not met as evidenced by:
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Licensee stated they are working on building an emergency fund by reviewing resident rental cost/care program. LPA Valerio to receive a statement from Licensee Shelly by POC due date.
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Based on records review, the licensee did not have sufficient cash resources to cover operating cost, which poses an immediate health, safety, and personal rights risk to 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: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2026
Section Cited
CCR
87468.2(a)(16)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)..:(16)To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident... this requirement was not met as evidenced by:
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Licensee stated the facility will ensure that if there are any resident room change, the facility will ensure a face to face meeting will occur, have a resident sign off on the notice, and ensure the resident has enough notice. LPA Valerio to receive a copy of policy and procedure by POC due date.
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Based on record reviews and interviews, the licensee did not ensure to give proper notice to the resident prior to moving residents to a different room, which poses an immediate health, safety, and personal rights risk to 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: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6