Legacy Lane Senior Living III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with facility staff Kirk Campbell, and explained the purpose of the visit. Facility staff contacted Assistant Administrator Esther Tabua via text to inform them of LPA's visit. LPA Valerio and staff toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed resident bedrooms. LPA Valerio observed four (4) resident bedrooms, which appeared to be clean and free from odors. LPA Valerio observed one bedroom to have a bathroom and shower. LPA Valerio observed the living rooms to be fully furnished. LPA Valerio observed residents in their bedrooms watching television, in the living room watching television, or in the room napping. LPA Valerio observed the facility kitchen. The facility was observed to have a two day supply of perishable food items and seven day supply of non-perishable food items. LPA Valerio observed the staff on shift conducting a medication audit. LPA Valerio observed the facility thermostat to show a temperature reading of 71 degrees F. The water in the bathroom delivered hot water at a temperature of 116.9 degrees F, which is within the regulatory range. LPA Valerio observed three (3) resident files. According to resident file, LIC 602, for Resident 1 (R1), R1 is unable to leave the facility unassisted; however, it was learned through interviews that R1 leaves to go obtain groceries and supplies for self. LPA Valerio observed the Medication Administration Record (MAR) for all residents. LPA Valerio observed the MAR signed off until the 28th of September. Today's date is September 25, 2026. LPA Valerio requested to see two (2) staff files for staff 1 and staff 2. According to staff on shift, staff 2 did not have a file at the facility. LPA Valerio requested the following annual documentation be sent to cclascpsacramentosouthro@dss.ca.gov: LIC 500, LIC 308, LIC 309, and copy of liability insurance. Per California Code of Regulations (CCR) - Title 22 - deficiencies are being cited on the attached LIC 809 - D page. An exit interview was held, and copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a plan of correction (POC) visit. LPA Valerio met with facility staff, and explained the purpose of the visit. On 07/24/2026, for complaint 27-AS-20260723122921, the facility was cited California Code of Regulations, Title 22, Section 87303 (b)(2) for not having a working air conditioning and allowing the facility to have a temperature above the regulatory range of 68 - 85 degrees Fahrenheit. Two health and safety visits were conducted on 07/25/2026 and 07/26/2026. No deficiencies were cited during those visits. On 07/25/2026, LPA Valerio received an email from the facility email with required POC documents On today's date, 08/03/2026, LPA Valerio inspected the facility to ensure the plan of correction has been met. The temperature inside the facility was observed to be LPA Valerio observed the main central heating and air conditioning unit to be set to 68 degrees F. LPA Valerio observed individual a/c units in each resident bedroom. The plan of corrections have been approved and met as evidenced by proof of correction visit. No deficiencies were cited on today's date. An exit interview was held with staff, Kirk Campbell, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2026

Type of visit: Case Management - Health Checks

On 7/26/2026, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check. LPA met with Kirk Campbell. All 5 residents were present and accounted for during the safety check. The temperature in the facility was a comfortable 74 degrees in the main area. The Licensee has purchased multiple window units and stand alone cooler in each of the rooms and all room check were at a comfortable 72-74 degrees. The construction is completed and the system is working. Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. An exit interview was conducted and a copy of the LIC 809 was provided to facility.the state’s words, verbatim · CDSS document, Jul 26, 2026

Type of visit: Case Management - Health Checks

On 7/25/2026, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check along with follow-up on incident reports. LPA met with Kirk Campbell. All 5 residents accounted for and present during the safety check. The temperature in the facility was a comfortable 75 degrees in the main area. The Licensee has purchased multiple window units and stand alone cooler in each of the rooms and all room check were at a comfortable 73-75 degrees. There was constructions/system replacement happening today. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the replacement construction project. An exit interview was conducted and a copy of the LIC 809 was provided to facility.the state’s words, verbatim · CDSS document, Jul 25, 2026

Allegation investigated: Facility is in disrepair Staff did not provide proper accommodations to residents in care

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a complaint investigation. LPA Valerio met with facility staff Kirk Campbell, and explained the purpose of today's visit. LPA Valerio spoke to Assistant Administrator Esther Tabua via cell phone. She designated staff to sign on her behalf. At 5:30PM, Licensing Program Manager (LPM) Stephen Richardson arrived to the facility to assist LPA Valerio. It is alleged that the facility's air conditioning has not working since mid-june. According to the Reporting Party (RP), despite ongoing complaints from residents, staff, family members, the facility has failed to make the necessary repairs or implement an effective solution to maintain a safe and comfortable living environment. Staff acknowledged that the air conditioning system was not functioning properly but were unable to provide information regarding when repairs would be completed. Residents have expressed ongoing discomfort and have reported difficulty resting, sleeping, and participating in daily activities due to the excessive heat." Continues on LIC 9099 -C... Substantiated On June 15, 2026, LPA Reza Jamaly and LPA Arvin Villanueva observed the facility to be 86 degrees Fahrenheit. LPAs observed electric fans were being utilized during this visit. LPAs observed resident rooms to have electric fans on. The living room and kitchen area - LPAs observed electric fans being utilized. Two maintenance individuals came on June 14, 2026 and June 18, 2026. The facility bought fans for the facility. On July 24, 2026, LPA Valerio observed the temperature outside the facility to be 92 degree Fahrenheit, with a high of 94 degree F. for the day. LPA recorded the temperature inside the facility to be measured 86 degree Fahrenheit, which is not within the regulatory range of 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. The thermastat was set to 58 degrees, but the air conditioning unit was not working. LPA Valerio took temperature recordings of resident bedrooms and hallways. The temperatures were 86, 88, and 89 degrees F. LPA Valerio took pictures for reference. According to the staff, the facility installed one window unit earlier in the day and was unaware if the other rooms would get one today. At 5:00 PM, LPA recorded the temperature to be 90 degrees Fahrenheit inside the facility. A picture reference was taken for future reference. At 6:00 PM, the temperature was record to be 90 degrees F. At 6:29 PM, the temperature in a resident's room was 92 degrees and residents were observed to take off their clothes to cool down. LPA Valerio spoke to 3 out of 4 residents present, which stated they felt hot but had been brought ice water from the staff. LPA Valerio observed two residents in long sleeved clothing, another resident in just their briefs, and another resident in pants and a short sleeve shirt. The staff, which is a live-in care staff, appeared to be sweating and stated they got used to the temperature. LPA Valerio attempted to contact Licensee Cleopatra Tania Gardiner; however, both calls were forwarded to voicemail. According to Assistant Administrator Esther, she did not have the contact information for alleged new administrator Shanice Downer. LPM recommended the resident's be relocated to a relocation cite but AA did not get back to LPA or LPM and stated that someone would come to the facility to bring coolers. Based on the aforementioned information, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 27-AS-20260723122921

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Jul 25, 2026

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2)The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C)... This requirement was not met as evidenced by: Based on observations, the licensee did not ensure to maintain a comfortable temperature for residents in care, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee stated they will install window unit air conditioners in every resident room and staff room by POC due date. LPA Valerio observed a man name Isaac to bring swamp coolers at 6:30 PM. LPA informed that another one needed to be brought. After 5:00 PM ,Administrator, Assistant Administrator, and Licensee did not answer LPA or LPM call or text.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Jul 25, 2026

87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility... This requirement was not met as evidenced by: Based on observations, the licensee did not ensure to have general supervision over the affairs of the facility and allowed the facility to maintain a temperature above a comfortable range, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee will submit statement of acknowledgement to LPA Valerio stating the report from today's visit was reviewed. Licensee will submit a plan to increase supervision of the facility affairs by POC due date of 07/25/2026. After 5:00 PM, Administrator, Assistant Administrator, and Licensee did not answer LPA or LPM call or text.

Allegation investigated: The Administrator is not present at the facility for a sufficient amount of time.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff Kirk Campbell, and explained the purpose of today's visit. LPA Valerio spoke to Assistant Administrator Esther Tabua via cell phone. She designated staff to sign on her behalf. The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility. Allegation: The Administrator is not present at the facility for a sufficient amount of time. According to an interview with staff, Administrator Moria comes once a week to assisted staff with administrative duties. LPA Valerio interviewed five (5) residents. Three out of five residents did not know anyone by the name of Moria and the other two residents were unable to provide a response. Continues on LIC 9099 - C... Substantiated LPA Valerio conducted two unannounced visits on 02/17/2026 and 07/24/2026. Administrator Moria was not present for either visit. On 06/16/2026, LPA Jamaly and LPA Villanueva conducted an unannounced visit and Administrator Moria was also not present for the visit. On 07/21/2026, LPA Valerio attempted to contact the facility and was unsuccessful in reaching any staff person. On 07/22/2026, LPA Valerio attempted to find contact information for Administrator Moria; however, there was none on file. On 07/23/2026, LPA Valerio emailed the facility requesting a call back. According to the LIC 500, Administrator Moria Gaunavou started on 09/23/2025 and is scheduled from Monday 1:00 PM to 5:00 PM and Thursday 1:00 PM to 5:00 PM. According to the LIC 500 dated 06/11/2026, there is a new administrator by the name of Shanice Downer. According to an interview with Administrative Assistant Esther Tabua, she is unaware of the number for Shanice Downer. LPA Valerio requested a copy of the staff file for Shanice Downer. The staff was unable to locate or provide the file to LPA Valerio. A search was conducted to determine if Shanice Downer had an active administrative certificate. It was discovered that Shanice does not have an active certificate. Therefore, the facility does not have a designated administrator to oversee facility operation. Based on records review, interviews, and LPA observation, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. Allegation: Staff are forging resident documents LPA Valerio reviewed the LIC 602 for Resident 1 (R1) to Resident 5 (R5). LPA Valerio confirmed that each LIC 602 had a signature from a medical professional. LPA Valerio attempted to confirm the validity of the signatures; however, LPA was unable to confirm or deny that the signatures were valid. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 27-AS-20260211124754

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Jul 27, 2026

87405 Administrator - Qualifications and Duties (a)...The administrator shall.. shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidenced by: Based on interviews, records review, and LPA observation, the licensee did not ensure there was a certified administratior on the premises, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Licensee to submit a 40 hour Administrator plan by POC due date to LPA Valerio

Type of visit: Case Management - Deficiencies

On June 15, 2026, Licensing Program Analysts, Reza Jamaly (LPA) and Arvin Villanueva (LPA), arrived unannounced at this facility conduct a case management visit. LPA initially met with staff on duty, Kirk Campbell (S1), and stated the purpose of the visit. The administrator assistant, Esther Tabua (S2), was notified and arrived later during the visit. This visit is being conducted concurrently with a complaint investigation (Complaint 27-AS-20260610160204). During this visit, LPAs conducted facility observation. LPAs observed the fire door, located at the kitchen area, was propped open by a door stopper (photo taken). Room temperature was at 86 degrees Fahrenheit. LPAs observed electric fans were being utilized during this visit. LPAs observed resident rooms to have electric fans on. The living room and kitchen area - LPAs observed electric fans being utilized. Per interview with S2, the air conditioner stopped working. Per S2 she called for maintenance person on Sunday, June 14, 2026, to come assess but was unable to fix. Another maintenance person will arrive this Thursday, June 18, 2026. S2 stated she ordered 7 electric fans for the facility to use. Some rooms have ceiling fans. Inside the refrigerator, LPAs observed 2 Ensures (photo taken). These Ensures are accessible to residents in care. Per review of 6 of 6 resident Medical Assessments (LIC602), at least one resident was assessed to be at risk if they have access to nutritional supplements. Based on today's visit, the facility is hereby cited and also assessed a civil penalty of $1000 due to a repeat violation. Plan of corrections and appeal rights were discussed with S2 during exit interview. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 17, 2026

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Based on observation, LPA observed, upon arrival to the facility, 1 of 2 fire doors were propped open with door stoppers. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Administrator assistant closed the fire door upon her arrival to the facility. Per discussion, the administrator assistant agreed to submit a staff training regarding fire safety, including those related to fire doors. Submit proof of training by 6/23/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(c) · Plan of correction due date: Jun 23, 2026

the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: LPAs observed 2 bottles of Ensures inside the kitchen refrigerator; per record review, at least one resident in care are at risk if they have access to nutritional supplements. This pose a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Staff removed the Ensures from the refirgerator and placed them in a locked cabinet. Per discussion, the administrator assistant agreed to submit a staff training regarding the regulation cited. Submit proof of training by POC due date.

Type of visit: Post Licensing

On 1/23/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct the Post-Licensing visit. LPA met with staff on duty, Omar Slypher (S1), and started the purpose of the visit. S1 notified the "company" of the visit. Present during this visit were 6 residents in care with one staff on duty (S1). Facility is a one-story home located in residential neighborhood. It is licensed to served up to 6 non-ambulatory residents. No clearance for bedridden, delayed egress, and locked exteriors/perimeter. Hospice waiver for 2 resident was granted. At this time, no residents in care are receiving hospice services. During this visit, LPA conducted a physical inspection of the facility. Inspection included, but not limited to, living area, kitchen, bedrooms, bathrooms, and outdoor spaces. All 6 residents were in their bedroom. LPA inspected bedrooms #1, #3, #4 and #5. Per fire clearance, room #5 on the facility sketch is a storage room. Room #4 is currently being utilized as a staff bedroom. Rooms #1 & #3 are double occupancy. 2 of 3 bathrooms were inspected. Advisory was provided to clean the cabinet under the sink in bath #1 on the facility sketch. LPA observed a piece of paper with black substance. LPA is unable to determine if it is mold. Hot water temperature was at 114 degrees Fahrenheit taken in both bathrooms. Room temperature was maintained at 75 degrees Fahrenheit. LPA observed the two fire doors to be propped open with door stopper placed at the bottom of the fire door. {1 of 2} For the outside area, ramps were observed to be in good repair at this time. The door of the storage shed at the back will need replacement, as the bottom right part of it is in disrepair. Inspection of the side exit gate, LPA observed the single-action latch has been broken and was replaced by a double-action locking mechanism by lifting and sliding the lever to unlock the gate. LPA reviewed 4 resident records, including those who have been discharged from the facility. LPA obtained copy of 2 resident files for further review. Based on today's visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An immediate civil penalty is hereby assess in the amount of $500 for the violation of CCR Title 22 Section 87203 Fire Safety An exit interview was conducted with S1 and a copy of this report and appeals rights were provided to the facility. {2 of 2}the state’s words, verbatim · CDSS document, Jan 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jan 24, 2026

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, LPA observed, upon arrival to the facility, the two fire doors were propped open with door stoppers. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2026

Plan of correction: Corrected on site: both fire doors were closed and door stoppers were removed by staff on duty. Per discussion with ___, they agreed to submit a written policy regarding fire door safety and compliance with State Fire Marshal regulations. Staff to receive training on fire safety procedures. Submit written policy and staff training by 2/2/2026.

Type of visit: Case Management - Other

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. {pg.1} 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. {pg.2}the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Prelicensing

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. 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.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Cleopatra Gardiner, Applicant Moria Gaunavou, Administrator Interview Method: Virtual interview (Microsoft Teams) On August 7, 2025, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License Type, Client/Resident Populations, and Program. 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readinessthe state’s words, verbatim · CDSS document, Aug 7, 2025