<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 05/22/2026
Date Signed: 05/22/2026 05:20:13 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
02/18/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260218102101
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:
05/22/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Donnabell GaliciaTIME COMPLETED:
05:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff fail to answer call lights timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

On 05/21/2026, LPA Valerio observed call lights were answered timely. The highest time in the last 24 hours was 12 minutes.

On 05/22/2026, LPA Valerio observed call lights were not answered timely before LPAs arrival. There were varying time frames such as 18, 24, 82, 12, and 42 minutes. According to staff interviews, sometimes it is forgotten to clear the light or the call pendant is missing.

LPA Valerio reviewed a Resident Council Meeting notes date May 7, 2026.

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

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
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 5
Control Number 27-AS-20260218102101
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: 05/22/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 9099

According to the Resident Council Meeting Notes, residents expressed concerns with call lights being answered timely. They specifically stated that response time to residents rooms is too slow, insufficient staffing levels at night, residents are not informed when new staff will be entering their rooms, and memory care staff observed sleeping, on phones, sitting idle during shifts

According to the posted Response from management to the resident council meeting, management responded with the following:

"Management has address response time expectation with staff. Ongoing communication, monitoring, and training are being conducted to improve response times.

Staff have been instructed to monitoring call systems and call logs more frequently to improve responsiveness and resident assistance.

Management has addressed these concerns directly with staff members. Resident are encouraged to continue reporting concerns to management so they can be addressed promptly."

Based on interviews, records review and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Per 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: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/18/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260218102101

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:
05/22/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Donnabell GaliciaTIME COMPLETED:
05:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide resident with housekeeping service
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation. LPA Valerio met with Administrator Donnabell Galicia, and explained the purpose of the visit.

Licensing Program Analyst (LPA) Christina Valerio conducted visits for other complaint investigations. During these times, LPA observed cleaning staff on shift.
04/21/2026 - LPA Valerio saw housekeeping cleaning inside the AL rooms
04/24/2026 - LPA Valerio saw housekeeping cleaning inside the AL rooms. LPA Valerio observed two housekeepers on shift
04/30/2026 - LPA Valerio saw housekeeping cleaning inside the AL room and MC room
05/04/2026 - LPA Valerio saw housekeeping walking in the hallway with her cart. LPA observed housekeeper to go inside the room.

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

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
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 5
Control Number 27-AS-20260218102101
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: 05/22/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
05/21/2026: LPA Valerio observed housekeeping cleaning AL rooms
05/22/2026 LPA Valerio observed housekeeping cleaning
- LPA Valerio saw 3 housekeeping; 2 in AL and 1 in MC. LPA observed and spoke to the person collecting the trash. Staff stated they come by every day to pick up the trash. There are only a few residents that say do not come to pick it up. Staff stated that residents can refuse trash pick or for staff to enter their room.

LPA Valerio observed the rooms that have posted signs stating when they preferred trash pick up.

Based on this information, the allegation is unfounded. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260218102101
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: 05/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2026
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, ... (4) To care, supervision, and services that meet their individual needs ... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated they will provide LPA Valerio a in-service training sign in sheet along with training materials and plan to hire additional staff by POC due date.
8
9
10
11
12
13
14
Based on observation, records review, and interviews, the licensee did not ensure staff answered call lights in a timely manner, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5