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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 09/04/2025
Date Signed: 09/22/2025 10:51:25 AM

Document Has Been Signed on 09/22/2025 10:51 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 IIFACILITY NUMBER:
342701578
ADMINISTRATOR/
DIRECTOR:		BANUVE, VENIANAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(279) 229-7719
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
09/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:18 PM
MET WITH:Licensee: Veniana BanuveTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 9/4/2025 at 12:00 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to conduct a case management regarding an elopement incident report received by the Dept on 9/3/2025. LPA met with facility staff Ula and the facility administrator Veniana Banuve. LPA explained the purpose of the visit. The current census is 6 residents with 1 facility staff.

LPA interviewed facility staff, regarding (2) separate incidents of elopement on 9/3 and 9/4/2025. Based on interview on 9/3/2025 facility staff was assisting another resident with changing their undergarments. Facility staff seen two residents R1 and R2 standing outside with their bags and a walker. Facility staff tired to redirect residents back into the facility. Staff contacted the administrator Veniana to assist with the residents leaving the facilities. Facility staff ran down the street to try to redirect residents but was unable to have the residents follow them back into the facility. Facility staff contacted R1's Responsible Party (RP) who was able to talk with both residents and persuade them to come back into the facility.

On 9/4/2025, resident (R2) asked facility staff if they could go to Walmart and to the Bank. Facility staff told the resident that they had to wait until the administrator came to transport them. The resident spoke with the administrator and facility staff who warned against leaving the facility unassisted. However resident (R2) still left the facility despite being warned not to leave.

R1 and R2's LIC 602, Physician Report was reviewed by LPA Hughes and it revealed that Resident (R1) and (R2) is unable to leave the facility unassisted. Interview with Administrator revealed the facility's internal plan includes providing supervision for all residents in care, including transportation to and from appointments.

Continuation 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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: 09/04/2025
NARRATIVE
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 Per administrator, Law enforcement was contacted to report the missing resident, and a report will be sent to CCLD to report the incident of elopement on 9/3/2025 and 9/4/2025 at the facility. As of 9/4/2025 R2 has eloped from the facility for the second time, and at the time of this report R2 has not returned.

Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued for the dates of 9/3/2025 and 9/4/2025 due to absence of supervision. An exit interview was conducted with administrator Veniana Banuve. A copy of this report LIC 809, LIC 809-D, LIC 421IM and appeal rights was provided to Veniana at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2025 10:51 AM - It Cannot Be Edited


Created By: Shakaricka Hughes On 09/04/2025 at 01:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVING LEGACY SENIOR CARE II
FACILITY NUMBER: 342701578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2025
Section Cited
CCR
87464(f)(1)

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87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by 9/5/2025 on how the facility will be in compliance with regulation 87464(f)(1) at all times. Administrator will read the regulation cited and provide LPA Hughes a letter of acknowledgement that the regulation cited was reviewed.
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Based on interviews with facility staff. The facility did not provide adequate care and supervision which resulted in R1 and R2 eloping from the facility on 9/3/2025. Additional elopement of R2 on 9/4/2025. This posed an immediate health and safety risk to residents in care
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 Additionally, Administrator agrees to conduct basic services training for all staff by 9/12/2025 and email LPA Hughes proof of training for all facility staff.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Shakaricka Hughes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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