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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 10/30/2024
Date Signed: 10/30/2024 10:03:46 AM

Document Has Been Signed on 10/30/2024 10:03 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:
10/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Cleopatra GardierTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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On 10/20/2024, Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived announced to conduct a Pre-Licensing Inspection follow-up of the facility to ensure compliance with Title 22 regulations. LPAs met with applicant Cleopatra Gardiner who assisted in today’s inspection.

The licensee will be the administrator to this facility. Administrator certificate number # 6069023740 and will expires on 04/15/2026. 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. The facility will not employ staff who are live-in caregivers but will have staff working shifts throughout the day/night for proper 24-hour care and supervision. There were no residents in care at this time. LPAs toured the facility with applicant and reviewed the facility sketch and the facility reflected the approved fire clearance STD 850 document. Applicant informed LPAs that this morning the pipe to the left of the home burst and that there is a flood on the side of the home. LPAs observed a maintenance guy working on the pipe. LPAs also observed the same fire extinguisher that was brought to the facility on 10/10/2024 from Diana Garcia with the service tag of 08/14/2024 and as a new extinguisher by Sacramento Fire Extinguisher Company with the Cert Reg. No. 7616 with the same signature. During today’s visit, the following corrections were not completed and must be corrected:

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

· Licensee/Administrator will ensure that there a new purchased fire extinguisher with receipt of purchase or a new service fire extinguisher. A copy of the receipt will be provided to the LPA upon purchase.

· Licensee/Administrator will ensure that the burst pipe is resolved and that there are no other leaks. A copy of services rendered shall be provided to the LPA upon completion.

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: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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