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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701003
Report Date: 06/27/2025
Date Signed: 06/29/2025 07:15:16 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
03/18/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20250318163724
FACILITY NAME:GOLDEN LEGACY ELDERLY CAREFACILITY NUMBER:
342701003
ADMINISTRATOR:STACY A SMITHFACILITY TYPE:
740
ADDRESS:1986 LEFORD WAYTELEPHONE:
(916) 629-9225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 5DATE:
06/27/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Care Staff Asena MotubulaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not administering resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegation. LPA Lund met with Care Staff Asena Motubula and explained the reason for the visit. LPA Lund called Licensee Diana Garcia who could not make the visit because of an emergency and gave permission for Care Staff Asena Motubula to sign required paperwork. Census: 5

Staff are not administering resident's medication as prescribed - LPA Lund reviewed facility records and interviewed staff. Residents (R1) LIC602A dated 3/5/2025 has a list of medications that R1 is prescribed. LPA Lund reviewed the medications and the medication that R1 stated that is supposed to be taking is not one of the prescribed medications on the list. LPA Lund was not able to interview R1becasue R1 is no longer a resident of the facility and doesn’t the whereabouts of R1.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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 2
Control Number 27-AS-20250318163724
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: GOLDEN LEGACY ELDERLY CARE
FACILITY NUMBER: 342701003
VISIT DATE: 06/27/2025
NARRATIVE
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Based on facility records reviewed, and interviews with staff on the information provided, it was unclear if staff are not administering resident's medication as prescribed, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2