<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701616
Report Date: 03/24/2026
Date Signed: 03/24/2026 04:02:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
02/09/2026 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260209110822
FACILITY NAME:LEGACY SENIOR CARE IIIFACILITY NUMBER:
342701616
ADMINISTRATOR:KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:9279 ORANGE CREST CT.TELEPHONE:
(916) 701-7737
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Mere FaletonoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived to the facility unannounced to deliver a complaint investigation. LPAs met with facility staff Mere Faletono, and explained the purpose of the visit. LPA contacted Licensee Adi Lina via cell phone and an option to leave a voicemail wait not an option.

During today's visit, LPA observed one staff on shift.
The following has been determined as it relates to the aforementioned allegation: Questionable Death of Resident 1 (R1) resulted from the neglect/lack of supervision from staff.

On January 12, 2026, R1 was observed by the facility to show signs of weakness and was out of baseline. Home health called paramedics and transported R1 to the Emergency Room.

Continues LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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 2
Control Number 27-AS-20260209110822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SENIOR CARE III
FACILITY NUMBER: 342701616
VISIT DATE: 03/24/2026
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
Based on the review of medical records, R1 remained in and out of the Intensive Care Unity during R1's admittance until 01/21/2026, when R1 was pronounced deceased. According to the death report, R1 died due to hypercapnic respiratory failure (days) due to obstructive sleep apnea due to severe obesity, and comorbidity - obesity hypoventilation. Based on the review of additional medical and facility records, R1 was on home health services for heart failure. Home health was aware of R1's sleep apnea and was in the process of addressing it with the primary care physician. Supporting records indicate R1 has change to had multiple pre-existed change to existing conditions that could have contributed to the cause of death.

Based on all the information collected by the Department, although the allegation may have happened or is valid, there 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2