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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701578
Report Date: 01/28/2026
Date Signed: 01/28/2026 11:17:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2026 and conducted by Evaluator Shakaricka Hughes
COMPLAINT CONTROL NUMBER: 27-AS-20260126091653
FACILITY NAME:LOVING LEGACY SENIOR CARE IIFACILITY NUMBER:
342701578
ADMINISTRATOR:BANUVE, VENIANAFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(279) 229-7719
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Facility Staff: Aisake JemesaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Lack of supervision resulting resident going AWOL and hit by a car causing multiple injuries.
INVESTIGATION FINDINGS:
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On 01/28/2026 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Aisake Jemesa and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 5.

Allegation: Lack of supervision resulting resident going AWOL and hit by a car causing multiple injuries.
It was alleged that lack of supervision resulted in a resident going AWOL and subsequently being hit by a car sustaining multiple injuries. This investigation consisted of records review, an interview with the reporting party, statements of the facility administrator, and a facility observation. On 1/28/2026 LPA Hughes conducted an unannounced visit to the facility. During the visit, LPA reviewed the resident record, LIC 602A Physician’s Report for resident (R1) which indicated that R1 is unable to leave the facility unassisted. On 1/27/2026, LPA conducted an interview with the reporting party, who stated that facility staff (S1) and (S2) were unaware of the resident leaving the facility on 1/24/2026. The reporting party further stated that R1 was struck by a car and sustained multiple injuries.
Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20260126091653
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/28/2026
NARRATIVE
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On 1/26/2026, LPA received a statement from the facility administrator (S1) reporting an incident in which (R1) eloped from the facility on 1/24/2026. LPA was unable to interview facility staff (S2) as staff (S3) stated that (S2) is no longer employed at the facility. During a tour of the facility, LPA observed the auditory alarms were present on the front door and on the resident bedroom (Room 4) sliding door leading to the backyard. However, despite these additional safety measures, R1 was able to leave the facility without staff supervision or awareness. The allegation was observed not in compliance with Title 22 regulation 87464(f)(1) Basic Services. As the facility did not ensure that a resident in care was kept under continuous supervision which resulted in elopement.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Aisake and a copy of the LIC 9099, LIC 9099-D pages, and Civil penalties were issued in the amount of $500 per the LIC 421IM and appeal rights were provided to facility.


 
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260126091653
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement was not met as evidenced by:
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The licensee will ensure the facility is in compliance with Title 22 regulation 87464 at all times. The licensee will conduct professional training with all facility staff working in the facility on care and supervision, and resident elopement. Licensee will send LPA proof of training by 1/29/2026.
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The facility did not ensure that a resident in care was kept under continuous supervision which resulted in elopement. On 1/24/2026 resident (R1) eloped from the facility, without facility staff awareness, and sustained multiple injuries as they were struck by a vehicle. Which poses in immediate Health and Safety risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3