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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 12/30/2025
Date Signed: 12/30/2025 11:39:55 AM

Document Has Been Signed on 12/30/2025 11:39 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:
12/30/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Facility Administrator: Veniana BanuveTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 12/30/2025 at 9:45 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to conduct a case management visit to the facility. LPA met with facility administrator Veniana Banuve. The purpose of this visit is to follow-up on a documentation request by the Dept. The current census is 6 with 1 facility staff.

LPA entered the facility and observed (2) residents siting in the kitchen area, LPA observed (3) additional residents in their bedrooms. LPA observed resident room 1 unclean with bottles of urine on the dressers. This was observed not in compliance with Title 22 regulation 87625(b)(3) Managed Incontinence. As the facility did not ensure that the residents bedroom was kept clean and free of odor.

During today's visit LPA spoke with the administrator regarding documentation requested by the Dept on 12/26/2025. LPA was able to retain the necessary documentation requested by the Dept. Additionally LPA spoke with the administrator regarding a resident (R1) who temporarily left the facility due to being hospitalized. Resident (R1) is currently residing back at the facility. The facility has an 30-Day Eviction Notice approved by the Dept, and has started legal proceedings to remove R1 from the facility. The facility administrator stated that they will assist the resident in searching for permanent housing, with the placement agency. Additionally, the facility will increase staffing to assist with residents care and needs in the facility by 12/30/2025.

An exit interview was conducted with Veniana and a copy of the LIC 809, LIC 809-D and Appeals Rights were 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: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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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Document Has Been Signed on 12/30/2025 11:39 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Shakaricka Hughes On 12/30/2025 at 11:10 AM
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: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
12/31/2025
Section Cited
CCR
87625(b)(3)

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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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The facility will ensure compliance with Title 22 regulation 87625 at all times. The facility will keep the facility clean, and free of incontinent odors at all times. The licensee agrees to employ additional staff to assist with residents care needs. Licensee will send LPA proof of additional staffing...
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This requirement was not met as evidenced by:
The facility did not ensure that residents room 1 was kept clean, and free of odor. LPA observed bottles of urine on the residents dressers. Facility staff discarded the waste, and cleaned the room.
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in the facility by 12/31/2025 via email.

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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: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
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