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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 05/21/2026
Date Signed: 05/21/2026 01:19:47 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
02/24/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260224160732
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 82DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Donnabell GaliciaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee does not ensure that residents care plans are being followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

The department reviewed facility records for Resident 1 (R1). Per facility records, R1 is not able to administer R1 own medications.

However, based on four (4) staff interviews, staff stated that R1 is allowed to pick up prescription medication from an outside pharmacy and at times held onto and self-administered these medications on multiple occasions.

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

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
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-20260224160732
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: 05/21/2026
NARRATIVE
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Continued from LIC 9099

An interview with staff revealed that the facility did not have a plan in place to address R1’s substance abuse despite R1 having a history of drug abuse and being suspected of possessing drugs on two separate occasions. However, efforts were continuously made in conjunction with R1s Care Coordination Agency to find another facility better suited for R1, without success. According to an interview with staff, staff reported that they felt if management had not been checking on staff, staff would not follow resident's care plan.

Based on interviews and records review, 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: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20260224160732
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: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan...shall be developed by each facility… (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee stated the facility attempted to find proper placement for R1 and attempted to update LIC 602 - Physician report to reflect current information. Licensee will send plan to address R1 picking up own medication and update LIC 602 by POC due date.
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Based on records review and staff interviews, the licensee did not ensure to put a plan in place to pick up R1's medications, which posed 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: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/24/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260224160732

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 82DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Donnabell GaliciaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not preventing resident(s) from having access to an illegal substance while in care.
Unqualified staff are providing nursing care to residents while in care.
Staff are being instructed to make false claims to CCLD.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint findings. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

Allegation: Staff are not preventing resident(s) from having access to an illegal substance while in care.

According to an Unusual Incident Report (UIR) dated February 24, 2026, a bag of undetermined white powdery substance was found in a medication bottle issued to R1 found in R1's room. R1 was out of the community at the time the bag was found.

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

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20260224160732
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: 05/21/2026
NARRATIVE
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Continued from LIC 9099 - A
According to the Sacramento County Sheriff's Office (SCSO) Report, the responding officer was unable to identify the white crystal-like substance. The officer noted that there were no other paraphernalia or substances found in the room; and that facility staff also had access to R1's room. R1 was not present for questioning by the responding officer. The substance was never tested or identified prior to destruction.

The department attempted to interview R1; however, R1 refused to provide a statement. According to staff interviews, staff suspected the white powder, found in R1's room, in a prescription bottle of Trazadone issued to R1 was an illegal substance but were unsure. Staff denied that R1 exhibited signs of being under the influence at any time.

According to interviews with residents, residents did not report being aware of any illegal substance being present in the community or being used in the community.

Allegation: Unqualified staff are providing nursing care to residents while in care.

According to Staff 1 (S1), S1 reported having training prior to working on the floor. S1 completed online training over four days and another four days of shadowing staff as they performed caregiver duties.  According to an interview with Staff 2 (S2), S2 reported received six day of training in total including online and shadowing their duties. S2 was hired to be behavioral specialist but has been scheduled as a caregiver. According to an interview with Staff 3 (S3), S3 stated Medication Technicians need to complete 16-20 hours on Relias and then two days of shadowing.  S3 reported that a staff member can only be a Medication Technician if they have been trained. A caregiver who does not have medication training cannot pass medications. According to an interview with Staff 4 (S4), S4 is able to be a medication technician and a caregiver because S4 has been trained to do both.

According to an interview with a resident, a resident reported that past medication technicians have expressed that they do not know their job. New medication technicians are allegedly teaching other new staff. This resident would not disclose names of the staff.

Continues on LIC 9099-C, Page 3...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20260224160732
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: 05/21/2026
NARRATIVE
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Continued from LIC 9099- C, Page 2

According to an interview with Staff 5 (S5), there was a new employee put on the floor; however, when they were put on the floor, they were not alone and with another staff member.

Allegation: Staff are being instructed to make false claims to CCLD.

According to interviews with staff, four (4) out of four (4) interviews reported that management does not instruct staff to make false claims or hide information.

According to interview with Resident 2 (R2), R2 stated staff encourage residents to voice their complaints so issues can be addressed. R2 reported that the facility has a Town Hall Meeting to report complaints to staff.
 
Based on all the information collected by the Department,  although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore the allegations are UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

An exit interview was held and a copy of report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6