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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920201
Report Date: 01/02/2025
Date Signed: 01/02/2025 02:57:45 PM

Document Has Been Signed on 01/02/2025 02:57 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY LANE SENIOR LIVING IIFACILITY NUMBER:
345920201
ADMINISTRATOR/
DIRECTOR:		GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:3039 WALNUT AVETELEPHONE:
(564) 200-1736
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 0DATE:
01/02/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Cleopatra GardinerTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On January 2, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a Pre-Licensing inspection. LPA met with Applicant, Cleopatra Gardiner and explained the purpose of the visit.

During today's inspection, LPA and Applicant conducted a tour of five residents room, staff room, bathrooms, kitchen, and the common areas. Applicant is designated to be Administrator, LPA observed Administrator Certificate #6069023740 to be active with expiration date of 04/15/2026. LPA observed a designated lock area for files, medications, sharps and toxins. LPA observed a fire extinguisher present with service date of February 28, 2024. LPA and Applicant discussed ensuring fire extinguishers are serviced annually. LPA observed auditory devices present on all exit doors, LPA observed the alerts to be working.

LPA observed facility to have preparation of seven days of nonperishable food present at the facility with a pantry of cereal, oatmeal, canned vegetables and grains. LPA observed facility having the presence of books and board games for activities. LPA observed the facility to have the required compliance posters posted in a conspicuous space. LPA observed the exterior of the facility to be free from obstruction in pathway. LPA observed First Aid kit to be recently purchased, filled with the requires items listed in 87465 Incidental Medical and Dental Care (a)(8)(A-F). LPA and Applicant discussed that facility is to have night lights maintained in hallways and passages to non private bathrooms. LPA observed nonskid mats presence in bathroom. File review conducted for template resident files, and observed the required documents.

Inspection tool completed and facility is in compliance to Title 22. Comp III waived. Applicant has passed the Pre-Licensing component of the application process. LPA will notify the Centralized Application Bureau of completion. Facility is not licensed until notify by Centralized Application Bureau Analyst along with a copy of license.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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