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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701414
Report Date: 11/01/2024
Date Signed: 11/01/2024 10:53:11 AM

Document Has Been Signed on 11/01/2024 10:53 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:
11/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Cleopatra Gardiner TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 11/01/2024 at 10:08 AM, Licensing Program Analyst (LPA) Pang Lee arrived announced to conduct a Pre-Licensing follow-up inspection of the facility to ensure compliance with Title 22 regulations. LPA Lee met with Cleopatra Gardiner who assisted LPA in today’s inspection.

LPA Lee toured the facility with Cleopatra Gardiner. During today's visit, all corrections were completed, and the applicant has passed the pre-licensing visit.

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

· 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. During today's visit, LPA observed a new fire extinguisher with a receipt date of 10/30/2024. COMPLETED

· 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. During today's visit applicant provided LPA Lee an invoice of sprinkler repair and PVC pipe repair. COMPLETED

LPA reviewed Component 3 with the applicant. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

An exit interview was conducted, and a copy of this report was given to the applicant.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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