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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701578
Report Date: 04/24/2026
Date Signed: 04/24/2026 03:25:02 PM

Document Has Been Signed on 04/24/2026 03:25 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:
04/24/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Kirk Campbell, staff on dutyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On April 24, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a case management visit. LPA met with staff on duty, Kirk Campbell (S1), and stated the purpose of the visit. S1 notified the assistant administrator who he identified as "John" but S1 stated he never answered or responded throughout this visit. When LPA asked if S1 know or seen Veniana Banuve, S1 stated he has not since he started working at this facility. S1 stated he only met "John" and "Kim" and identified them as "management." "John" arrived at 3:00 pm.
Present during this visit were 5 residents in care with one staff on duty (S1). Fire door was observed to be closed upon arrival.
The purpose of this visit is to return the resident (R1), files and staff files that were removed on April 23, 2026, for the purpose of copying files at the Regional Office. Files were handed to S1 during this visit.
Additionally, the purpose of this visit is to continue the post-licensing inspection that was initiated on April 23, 2026.
Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.
LPA and S1 inspected 3 of 5 resident bedrooms and 2 of 2 bathrooms. Hot water temperature was taken in both bathroom – temperature was between 150 and 151 degrees Fahrenheit.

In the kitchen, LPA observed 3 kinds of fruits (half a bag of apples, nearly empty container of blue berries, and one whole avocado). LPA did not observe fresh vegetables in the refrigerator. Per review of the sample menu provided by S1, vegetables are included such as green salad, for lunch and cabbage slaw for dinner, as example.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2026
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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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: 04/24/2026
NARRATIVE
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One fire extinguisher was observed in the kitchen area and was last inspected on March 18, 2026. The cabinet under the kitchen sink where they keep cleaning chemicals and sharps was observed to be accessible as evidenced by being secured by a plastic “child proof locking device” but can be unlocked without a key. Per S1, they use this device during the day but uses a lock with a key at night. LPA informed S1 that dangerous items need to be always locked and not accessible to residents in care. Dishwasher was not working during this visit. S1 stated a repair request has been initiated but unsure when it will be done.

The garage is not accessible to residents in care, and it is kept locked and can be accessed with a key.

The sliding door at the living room/kitchen area leading to the backyard was difficult to slide open.

Outdoor area was inspected. S1 was unable to correctly identify, locate. and know how to operate each of the shut off valves. Per S1, he was not oriented on these. Walkway to the exit gate was obstructed by a wood bookshelf/cabinet, a white shower chair, and some type of green ceramic plant pot. Someone who uses a wheelchair would not be able to get through immediately during an emergency.

Based on today’s visit, deficiencies are being cited and advisories were provided.

Exit interview was conducted with with Veniana over the phone and gave permission to S1 to sign this report. A copy of this report and appeal rights were provided.

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

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/24/2026 03:25 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/24/2026 at 02:48 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: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The hot water temperature in both bathroom faucet were measured between 150 and 151 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2026
Plan of Correction
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Per discussion over the phone, Administrator has agreed to adjust the water heater and send the reading to the Department by end of day on April 25 2026.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above. The cabinet under the kitchen sink where they keep kitchen knives, dish detergents and cleaning solutions can be unlocked without a key, which makes it accessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2026
Plan of Correction
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Corrected on site: Staff on duty replaced the plastic child lock with a bicycle lock that can be locked/unlocked by a key.
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: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2026 03:25 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/24/2026 at 02:48 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: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Walkway to the only exit gate at the side was obstructed by items such as wood bookshelf/cabinet, shower chair and a large plant pot. Someone with wheelchair would not be able to fit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Corrected on site: staff removed the items and cleared the walkway during this visit.
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Inspection of the kitche, LPA did not observe fresh vegetables and enough perishable food to accomodate 5 residentws, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Per discussion, admin agreed to provide a written plan of correction on the specific steps the facility will take to ensure the facility maintains an adequate supply of perishable foods (including vareity of fresh fruits and vegetables) to meet the needs of residents, which include documentaion of residents' food preferences and diet orders. Submit plan by end of day on Arpil 30, 2026.
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: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
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