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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 04/08/2026
Date Signed: 04/08/2026 04:18:34 PM

Document Has Been Signed on 04/08/2026 04:18 PM - 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: 5DATE:
04/08/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Lorima Niumataiwalu, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On April 8, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management visit to issue deficiencies based on a complaint investigation visit (Complaint #27-AS-20260407081657) conducted on the same day. LPA met with the assistant administrator, Lorima Niumataiwalu (S2), and stated the purpose of the visit. The administrator, Veniana Banuve, was notified but according to S2 she never responded.

Regarding the fire door:
Throughout this visit, the fire door leading to the kitchen/dining/living room area was propped open by a dining chair. Per review of staff orientation training records revealed that staff were oriented/trained on Building and Fire Safety and appropriate response to emergencies. This training was 2 hours.

Per interview with staff on duty, Kirk Campbell (S1), he stated that they keep the fire door propped open during the day and close it at night. Per S2, he stated that one resident has difficulty with opening it due to their walker. S2 admitted that the fire door needs to be closed at all times and corrected this deficiency by removing the dining chair and closing the door at approximately 3:37pm. LPA consulted S1 and S2 that they need to comply with applicable laws and regulations.


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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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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Document Has Been Signed on 04/08/2026 04:18 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/08/2026 at 02:28 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: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2026
Section Cited
CCR
87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Corrected on site: after consulting with the assistant administrator, he removed the dining chair.
Additional corrective action was discussed with the assistant admin.
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Based on observation, the fire door was propped open with a dining chair throughout this visit. This poses an immediate health, safety, and personal rights risks to persons in care.
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Per discussioin, they agreed to conduct in-service training with staff and residents to discuss fire safety, including the requirements relating to fire doors. Proof on training shall be submitted to the Department by 4/15/2026.
Type B
04/15/2026
Section Cited
CCR87412(g)

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(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
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Per discussion with assitant admin, the licensee/administrator shall develop a written plan to ensure all personnel records are maintained at the facility and available for review during the Department's visit or upon request by the Department.
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Based on record review and interviews, S1's health screen record was missing the second page; and S2's records were not available for review upon request. This poses a potential health, safety, and personal rights risks to persons in care.
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Written plan shall be submitted by POC due date on 4/15/2026 no later than 5pm.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/08/2026 04:18 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/08/2026 at 03:41 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: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2026
Section Cited
CCR
87506(d)

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(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
This requirement was not met as evidenced by:
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Per discussion with assitant admin, the licensee/administrator shall develop a written plan to ensure all residents' records are maintained at the facility and available for review during the Department's visit or upon request by the Department.
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Based on record reviews and interviews, the licensee did not comply with the regulation cited. R3's Medical Assessment and Needs and Services Plan were not available for review during this visit. This poses a potential health, safety, and personal rights risks to persons in care.
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Written plan shall be submitted by POC due date on 4/15/2026 no later than 5pm.

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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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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: 04/08/2026
NARRATIVE
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A review of California Building Code (CBC) 425.8.3.2 Group R-3.1 Occupancies Housing Nonambulatory Clients states "The hallway shall be separated from the common areas by a solid wood door not less than 13/8inch in thickness, maintained self-closing or shall be automatic closing by actuation of a smoke detector."

According to CCR 87405(d)(2), the administrator is expected to have "Knowledge of and ability to conform to the applicable laws, rules and regulations." This include fire safety regulations adopted by the State Fire Marshal.

Regarding personnel records:
During a review of personnel records, it was revealed that S2's files were not available at this facility for review. Also, S1's Health Screen (LIC503) was missing the second page that include the TB test result.

Regarding resident records:
During a review of resident records, one resident (R3) did not have their Medical Assessment (LIC602A) and Needs and Services (LIC625) were not on file and not available for review during this visit.

This facility is hereby cited per Title 22, Division 6, Chapter 8. Additionally, an immediate civil penalties in the amount of $500 is being assessed today based on fire safety violation. An exit interview was held with Lorima and Plan of Corrections were discussed. Appeal rights and a copy of this report were handed to Lorima.


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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
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