345920201-4-22-2026-59-AS-LMUZ-DVENG5-20260626102633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920201
Report Date: 04/22/2026
Date Signed: 04/22/2026 04:31:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2026 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260420092822

FACILITY NAME:	LEGACY LANE SENIOR LIVING II		FACILITY NUMBER:	345920201
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	3039 WALNUT AVE		TELEPHONE:	(916) 664-3914
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Christina Allen, Overseer		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not keep facility free from pests.

Staff not following resident’s dietary needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 59-AS-20260420092822

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 345920201
	VISIT DATE: 04/22/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA conducted an inspection of the care home on April 21, 2026. LPA observed a cockroach in resident (R1's) bedroom during visit. Interviews conducted with residents R1, R2, R3, and R4 indicated that they have observed cockroaches in their bedrooms and on the premises. Interviews with residents R1, R2, R3, and R4 indicated that they haven't witnessed pest control at the facility to address current issue with cockroach infestation. Interviews with staff indicated that that they could not recall when pest control last provided treatment at the facility. During visit conducted on April 22, 2026, LPA observed a black widow in the living room of the care home, as well as R4's bedroom. LPA was not provided any current documented proof of pest control services completed at the facility by the conclusion of this investigation.

Allegation: Staff not following resident’s dietary needs.

Relevant party reported that facility staff are not providing meals to R1 that abide by their special diet. Relevant party reported that R1 is allergic to milk and wheat. Interview with R1 indicated that they want to eat food that is a part of their special diet and staff are not providing food that belongs with their special diet. R1's Physician's Report (LIC 602A) dated January 29, 2025 states R1 has a special diet which includes "gluten free, dairy free." R1's Resident Appraisal (LIC 603A) dated February 1, 2025 indicates "yes" for special diet/observation of food intake as "gluten & dairy free." R1's Admission Agreement dated February 1, 2025 states "Basic services at a minimum include: (5) Food Services: 2. Special diets if prescribed by a doctor."

During visit conducted on April 22, 2026, LPA observed staff member (S1) serve a sandwich to R1 for lunch. R1 inquired if it was bread she could eat, and S1 stated that the bread was healthy. LPA observed bread bag of bread used in R1's sandwich and observed bread contained wheat gluten and may contain traces of milk.

Based on observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20260420092822

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 345920201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/05/2026 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will contract for regular pest control services to address pest infestation, including, but not limited to, spiders and roaches . Facility will provide a copy of the contract for pest control services to LPA by POC due date of May 5 , 2026.
	8 9 10 11 12 13 14	Based on observations, interviews conducted, and records reviewed, the facility did not ensure that premises was free from pests, including multiple bedrooms for residents, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 05/05/2026 Section Cited CCR 87555(b)(7)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will immediately post all residents special diets for staff and begin providing meals to residents that abide by their modified diets. Facility will provide a training to staff regarding special diets and provide proof of training to LPA by POC due date of May 5, 2026.
	8 9 10 11 12 13 14	Based on observations, interviews conducted, and records reviewed, the facility did not ensure that R1 was provided food belonging to their medically prescribed modified diet, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2026 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20260420092822

FACILITY NAME:	LEGACY LANE SENIOR LIVING II		FACILITY NUMBER:	345920201
ADMINISTRATOR:	GAUNAVOU, MORIA		FACILITY TYPE:	740
ADDRESS:	3039 WALNUT AVE		TELEPHONE:	(916) 664-3914
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Christina Allen, Overseer		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have phone accessible for residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Overseer, Christina Allen, to deliver complaint investigation findings regarding the allegation listed above.

During investigation, LPA conducted interviews and toured the premises. LPA observed house phone missing but staff had cell phone readily available for resident use per observations and interviews with staff S1, S2, and S3. Facility replaced house phone during initial visit. Interviews with residents R2, R3, R4, R5, and R6 did not express any concerns regarding the facility not having a phone available.

Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4