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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701615
Report Date: 08/29/2025
Date Signed: 09/19/2025 11:08:02 AM

Document Has Been Signed on 09/19/2025 11:08 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:LEGACY LANE SENIOR LIVING IIIFACILITY NUMBER:
342701615
ADMINISTRATOR/
DIRECTOR:		GAUNAVOU, MORIAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(564) 200-1736
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
08/29/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Moria GaunavouTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 8/29/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct pre-licensing inspection. LPA met initially met with staff on duty (S1) and explained the purpose of the visit. The Licensee, Cleopatra Gardiner, was notified to the visit. Per Licensee, she is unavailable at this time and will send her Administrator, Moria Gaunavou (AD), to assist with this pre-licensing. At around 11AM, AD arrived.

Overview: Facility is a one-story home located in a residential neighborhood. Facility will be licensed to serve up to 6 elderly residents.

Initial Observation: Upon arrival LPA was greeted by staff on duty (S1). Present during this visit were 4 residents in care, with one staff on duty (S1). 1 resident was in the second living room area, and 3 resident were in their bedroom. Room temperature was at 72 degrees Fahrenheit upon arrival.

Physical Inspection:

Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 6 resident bedrooms. Based on the review of Fire Safety Inspection (STD850), Bedrooms #1 through $4 are currently occupied; Bedrooms #6 is currently vacant; Bedroom #5 was approved for non-ambulatory resident. However, Bedroom #5 is currently being utilized as a staff room. Further inspection of Bedroom #5, LPA did not observe the room to have any windows; LPA did not observe a closet; LPA observed the staff bed to be barely fitting the room, causing the door to not open all the way. LPA contacted the Fire Inspector via phone to verify/confirm the accuracy of the STD850 report.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2025
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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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: LEGACY LANE SENIOR LIVING III
FACILITY NUMBER: 342701615
VISIT DATE: 08/29/2025
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LPA measured the hot water temperature in the 3 of 3 bathrooms to be between 113 to 116 degrees Fahrenheit. All resident bathrooms were observed to be in good repair at this time.

The garage is locked and not accessible to residents in care.

Fire extinguisher was observed at the medication area, leading to the dining area; and it was last inspected on 1/8/2025. Smoke and carbon monoxide detectors were observed throughout, tested and found operable at this time.

In the kitchen area, LPA observed at least seven day non-perishable and two day perishable food supplies. Kitchen refrigerator and freezer were maintained at regulatory temperatures. Medication cabinet was observed to be locked and not accessible to residents in care. Toxic materials, cleaning supplies, sharp objects and other dangerous items were observed to be in locked storage.

Outdoor area was inspected. LPA observed outdoor furniture for resident use. Emergency walkways were observed to be unobstructed. Facility has one exit gate and was observed to be in good condition at this time. The fence at the right side of the facility, part of it was observed to be wobbling.

THE FOLLOWING ADVISORIES WERE PROVIDED TO ADMINISTRATOR:
  • REPAIR FENCE ON THE RIGHT SIDE OF THE FACILITY WAS OBSERVED TO BE WOBBLY
  • REPAIR DOOR THAT EXITS TO THE BACKYARD NEEDS REPAIR - BOTTOM PART IS COVERED WITH TAPE.
  • CLEAN/ORGANIZE THE GARAGE.
  • PLACE A LOCK ON THE CLOSET THAT STORE THE WATER HEATER.
  • ENSURE ALL STAFF FILES, INCLUDING ADMIN , ARE COMPLETE AND IN THE FACILITY AVAILABLE FOR REVIEW AT ANY TIME.
  • ENSURE ALL RESIDENT RECORDS ARE UPDATED TO THE NEW LICENSE.

Component III was conducted with AD.
Based on the today's inspection, this Pre-Licensing is on hold and will require a continuation. LPA is waiting for Fire Inspector to verify/confirm the status of Bedroom #5.
Exit interview was conducted and a copy of the report was provided upon exit.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
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