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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 10/10/2024
Date Signed: 10/10/2024 11:59:30 AM

Document Has Been Signed on 10/10/2024 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY LANE SENIOR LIVINGFACILITY NUMBER:
342701414
ADMINISTRATOR/
DIRECTOR:		GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:7610 LA MANCHA WAYTELEPHONE:
(564) 200-1736
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 14CENSUS: 0DATE:
10/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Cleopatra Gardiner.TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 10/10/24 at 8:30 AM, Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPAs met with applicant, Cleopatra Gardiner. Licensee assisted LPAs in today’s inspection. This Applicant is seeking licensure for a 14 non-ambulatory Residential Care Facility for the Elderly (RCFE) to accept and retain at any given time with a perspective of hospice waiver for two. This facility will also have a dementia plan on file. The facility will not have live in staff and will provide 24/7 care to residents. There were no residents at this time. A brief interview with applicant Gardiner was conducted.

Cleopatra Gardiner will be the Administrator of this facility. The facility administrator’s certificate # is 6069023740 and will expire 04/15/2026. Per Guardian and LIC 500 Personnel Report, the proposed administrator Cleopatra Gardiner to this pending facility is also associated to two other facilities Love and Comfort Elderly Care and Vita Bella Elderly Care III as the administrator. The facility has an infection control plan and an emergency disaster plan completed and provided to Licensing for approval.

LPAs toured the facility and inspected the kitchen area. Cabinets and drawers were opened and reviewed at this time. Silverware, plates, and utensils were observed to be sufficient to meet the needs of the residents at this time. Knives were observed to be made inaccessible to the residents at this time. The food storage unit, facility refrigerator, was observed to be functional and in good repair at this time. Food supplies were reviewed for adequate 2-day perishables and 7-day non-perishable quantities, and they both were observed not sufficient at this time. LPAs observed 37 cans of various canned goods, a pack of 6 instant ramen, 4 packs of spaghetti noodles, a container of quick oats, macaroni and cheese, cereal and 12 cans of Pepsi Soda. LPAs observed cleaning supplies and laundry supplies were made accessible to the residents at this time. Cleaning and laundry supplies were stored inside the washer such as Clorox, window, tide, and fabric softener. The common area and dining area were observed to be furnished and not sufficient to seat and meet the needs of the 14 residents at this time. LPAs observed 6 seats around the dining table with no additional seating.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 LANE SENIOR LIVING
FACILITY NUMBER: 342701414
VISIT DATE: 10/10/2024
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 LPAs observed a telephone made available to residents in the kitchen. The facility smoke detectors and carbon detectors were observed to be in good condition. The fire extinguisher was last serviced on 10/10/2023. LPAs observed two additional fire extinguishers on the kitchen counter; however, administrator were not able to locate the receipt of purchased. At 9:40 AM, it was learned that a care staff Diana Garcia from Vita Bella Elderly Care II came to the facility to drop off a fire extinguisher that was last service on 08/14/2024 as a new extinguisher by Sacramento Fire Extinguisher Company with the Cert Reg. No. 7616. Linen closet was observed and had sufficient supply of sheets, bedding, pillowcases, and blankets to meet the needs of the residents at this time. Residents’ bedrooms were toured, and furniture and furnishings were observed to be sufficient and able to meet the needs of the residents.

A tour of the staff bedroom was conducted. LPAs observed that there was not a door that would ensure that the stairs were inaccessible to the residents in care. LPAs observed a mattress on the floor.

The water temperature measured in 3 bathrooms were conducted. Bathroom one had water temperature of 137.5 degrees Fahrenheit, bathroom 2 had a water temperature of 135.5 and bathroom 3 had a water temperature of 65.8. The facility temperature measured at 67.1 degrees. LPAs observed the centrally stored medication areas to be locked. LPAs inspected the first aid kit, and it was not complete. First Aid kit was missing a thermometer and A current edition of a first aid manual approved by the American Red Cross. LPAs observed there were sufficient supply of hygiene items on the premises made available to residents in care. LPAs observed facility has a designated area for residents and staff files, which is kept locked. LPAs also observed required posters posted. LPAs did observe>? activity supplies made available for residents at this time. LPAs toured the garage and observed miscellaneous items stored in the garage. LPAs advised administrator that the piles of miscellaneous items will need to be declutter and cleaned up. LPAs toured the courtyard and did not observe the courtyard having sufficient furniture made available for residents in care at this time. LPAs observed the courtyard to be hazardous with exposed wires, wood planks, shatter glasses and outgrown shrubs and tree branches. It was also observed two exit gates in the courtyard are not self-closing or latching.

LPAs discussed with the applicant that the following items must be corrected:

· Licensee/Administrator will ensure to declutter and clean out the miscellaneous in the garage.

· Licensee/Administrator will ensure that the facility have sufficient supplies of 2 days perishable and 7 days non-perishable for 14 residents in care at all times.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 LANE SENIOR LIVING
FACILITY NUMBER: 342701414
VISIT DATE: 10/10/2024
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· Licensee/Administrator will ensure that all chemicals/toxins are made inaccessible to residents.

· Licensee/Administrator will ensure that the facility has a first aid kit including a thermometer and a current first aid manual.

· Licensee/Administrator will ensure that there is a serviced fire extinguisher at all times.

· Licensee/Administrator will ensure that there is sufficient seating in the courtyard made available to residents.

· Licensee/Administrator will ensure that all the exposed wires, wood planks, shatter glass and outgrown shrubs and tree branches are cleaned and discard.

The Applicant has not passed the pre-licensing component of the application process. The applicant will correct issues and inform LPA when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the Applicant.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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