342701578-7-2-2025-27-AS-SHUS-DJ7P6R-20250702110247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 07/02/2025
Date Signed: 07/02/2025 11:02:57 AM

Document Has Been Signed on 07/02/2025 11:02 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:	LOVING LEGACY SENIOR CARE II		FACILITY NUMBER:	342701578
ADMINISTRATOR/ DIRECTOR:	BANUVE, VENIANA		FACILITY TYPE:	740
ADDRESS:	6532 RANCHO GRANDE WAY		TELEPHONE:	(279) 229-7719
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 6		CENSUS: 5	DATE:	07/02/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:07 AM
MET WITH:	Administrator: Veniana Banuve		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	On 7/2/2025 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes and Pang Lee arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Hughes met with Administrator Veniana Banuve. Licensee assisted LPA Hughes in today’s inspection. This Applicant is seeking licensure for a (6) non ambulatory Residential Care Facility for the Elderly (RCFE) to accept and retain at any given time. The facility will have 2 staff, 1 of which will be a live-in care staff. There are 5 residents at this time. Veniana Banuve will be the Administrator of this facility. The facility administrator’s certificate # 7030527740 and will expire 04/19/2027. The facility has an infection control plan and an emergency disaster plan completed and provided to Licensing for approval. The facility fire clearance has been approved as of 6/24/2025. LPA Hughes toured the facility, Residents’ bedrooms were observed, and furniture and furnishings were observed to be sufficient and able to meet the needs of the residents. LPA Hughes 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, cleaning agents, and bleach were observed to be locked and made inaccessible to the residents at this time. Continuation 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: LOVING LEGACY SENIOR CARE II	FACILITY NUMBER: 342701578
	VISIT DATE: 07/02/2025

NARRATIVE

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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 sufficient at this time. The living room and dining area were observed to be furnished and sufficient to meet the needs of the residents at this time. LPA Hughes observed a telephone made available to residents in the kitchen. The facility smoke detectors, carbon detectors and fire extinguisher were observed to be in good condition. The fire extinguisher was last serviced on 08/20/2024. Linen closet was observed with a sufficient supply of sheets, bedding, pillowcases, and blankets to meet the needs of the residents at this time. The water temperature measured at 121.4 degrees Fahrenheit, and the facility temperature measured at 73 degrees. LPA Hughes observed the centrally stored medication areas to be locked. LPA Hughes inspected the first aid kit, and it was complete with all required components. Emergency flashlights, and batteries were observed sufficient at this time. Resident records, staff records, were observed in a hallway closet locked and inaccessible to residents in care. LPA reviewed 5 out of 5 resident files and they were complete. LPA reviewed 2 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared

LPA Hughes, toured the outside of the facility, and observed outside area enclosed by a fence, stairways, inclines, and outdoor passageways, and self latching side gate was observed free of obstruction, and accessible to residents in care. Outside activity area is equipped for activity outdoor use. LPA toured the garage area, and observed resident hygiene items, cleaning chemicals, toxins, and other supplies located above the washer and dryer. Washer, Dryer and water heater was observed to be in good repair at this time. LPA Hughes discussed and recommended the Technical Support Program (TSP) to the applicant. Veniana, the applicant expressed interest in being recommended to the program. LPA Hughes advised the applicant that a referral to TSP will be completed.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. The applicant has passed the pre-licensing component III of the application process. LPA Hughes 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 has been provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025

LIC809 (FAS) - (06/04)

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