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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701615
Report Date: 09/19/2025
Date Signed: 09/19/2025 12:37:38 PM

Document Has Been Signed on 09/19/2025 12:37 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: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:
09/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Moria GaunavouTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 9/19/2025, Licensing Program Analysts, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a case management continuation visit to continue the pre-licensing inspection initiated on 8/29/2025. LPA initially met with the staff on duty and stated the purpose of today’s visit. The licensee, Cleopatra Gardiner, was informed of the visit and instructed the administrator, Moria Gaunavuo, to be present for this visit. Moria arrived at 12:28pm. Present during this visit were 3 residents with 1 staff on duty.

Overview: During the previous visit on 8/29/25, this LPA requested another fire inspection to be conducted due to Bedroom #5 on the facility sketch being approved for a non-ambulatory resident. However, it was noted that Bedroom #5 is currently being used as a staff room. Upon further inspection of the room, LPA observed that it lacked windows and a closet. Additionally, the staff bed barely fits in the room, preventing the door from fully opening. The LPA contacted the Fire Inspector to confirm the accuracy of the STD850 report.

Based on the new fire inspection report conducted on 9/15/2025:
  • Bedroom #5 on the facility sketch cannot be used for sleeping purposes as there is no egress/exiting from the bedroom; this room can only be used for storage only.
  • Bedroom #4 on the facility sketch has been approved for staff or 1 ambulatory resident use only; this room is not cleared for non-ambulatory.
  • Bedrooms #1, 2, 3, & 6 on the facility sketch are approved for ambulatory and non-ambulatory residents.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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: LEGACY LANE SENIOR LIVING III
FACILITY NUMBER: 342701615
VISIT DATE: 09/19/2025
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The facility administrator, Moria, was instructed to update the facility sketch (LIC999) to designate Room #5 for storage purposes only. Additionally, LPA directed Moria to include the location of the 2 fire doors on the facility sketch. Facility sketch must be submitted by end of business day on 9/19/2025.

Additional advisories were provided to switch the numbers on the room doors for #5 and #6 to match those listed on the facility sketch.

During this visit, LPA noted that the following issues from the previous inspection have been addressed:
  • The fence on the right side of the facility, which was unstable during the last inspection, has been repaired.
  • The exit door leading to the backyard has been repaired as instructed.
  • The garage has been cleaned and organized.
  • The door knob on the closet housing the water heater has been replaced with a lock.

The applicant has completed the pre-licensing component of the application process. LPA Villanueva will notify the Central Application Bureau (CAB).

Note that Component III was completed on 8/29/2025.

An exit Interview was conducted with Moria, and a copy this report was provided to the facility.









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

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
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