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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006276
Report Date: 03/21/2025
Date Signed: 03/21/2025 11:54:47 AM

Document Has Been Signed on 03/21/2025 11:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LEGACY SENIOR LIVINGFACILITY NUMBER:
306006276
ADMINISTRATOR/
DIRECTOR:		TRAN, HONGLANFACILITY TYPE:
740
ADDRESS:19892 POTOMAC LNTELEPHONE:
(714) 785-9555
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:18 AM
MET WITH:Alfredo OrdonTIME VISIT/
INSPECTION COMPLETED:
01:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin made an unannounced visit to conduct the required annual inspection. LPA met with caregiver (staff), Alfredo Ordon, and explained the reason for the visit. LPA toured the interior and exterior portions of the facility with staff and observed the following: This is a one-story home. Facility is a 5-bedroom, 2-bathroom, 1 story house with attached garage that is being used for storage. Resident rooms were provided with furniture, chair and clean Lenin adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars.

At around 10:38Am, LPA checked the hot water temperature in both restrooms, and it measured between 94.9- and 99.1-degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. LPA inspected kitchen appliances and noticed 2 out of 4 stove burners were not operational. Staff stated that both burners have been out since October of last year and staff advised administrator back then.

Fire extinguisher was observed fully charged and indicator in the green zone with inspection date of December 6th, 2024. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards and ample space for activities. The facility has a pool that is fenced and is inaccessible to residents in care

Kitchen was in good repair with cleaning supplies and sharp items inaccessible to residents in care. Medications are kept locked separately in hallway. LPA reviewed two residents’ files and medications with no discrepancies observed. All files of staff and residents contained all required documentation. Upon review of records, the facility could not provide any log regarding the required quarterly fire drill.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights provided to AD at end of inspection.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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
Document Has Been Signed on 03/21/2025 11:54 AM - It Cannot Be Edited


Created By: Samer Haddadin On 03/21/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature measured at 94.9 DF and 99.1 DF which poses an immediate health, safety risk to persons in care.
POC Due Date: 03/22/2025
Plan of Correction
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AD and or staff will send proof of water temperture (between 105 and 120FF) to LPA by e mail by POD due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/21/2025 11:54 AM - It Cannot Be Edited


Created By: Samer Haddadin On 03/21/2025 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having only 2 out of 4 stove burners working. which poses personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Stafe or licensee will send proof of all four stove burners working to LPA by POC due date
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review)], the licensee did not comply with the section cited above in not providing proof or conducting quarterly emergency drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2025
Plan of Correction
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Staff and or licensee will send proof to LPA by e mail by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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