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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701616
Report Date: 08/03/2026
Date Signed: 08/03/2026 02:26:03 PM

Substantiated


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
02/11/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260211105253
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:
08/03/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sera NakalevuTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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The Administrator is not present at the facility for a sufficient amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with direct care staff, Mere, and explained the purpose of the visit. Facility staff informed person who oversees the facility, Jackee, of LPAs arrival.

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.

On 02/17/2026, LPA Valerio did not observed Administrator Tevita Kaloulasulasu present in the facility. Administrator Tevita was also not present during 02/09/2026, 02/11/2026, 03/24/2026, and 05/11/2026 visits. Based on interviews with Licensee Adi Lina, licensee stated Tevita was the administrator but could not provide proof of Administrator being present in the facility.
Continues on LIC 9099 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
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 5
Control Number 27-AS-20260211105253
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: 08/03/2026
NARRATIVE
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On 03/11/2026, Administrator appointed Sera Nakalevu as the administrator. On 05/11/2026, LPA contacted Sera, which stated she is the administrator for both Vita Bella Elderly Care III and Legacy Senior Care III. LPA Valerio did not observe Sera at the facility during the 05/11/2026 visit.

According to interviews with residents, they were unaware of who the administrator, Tevita Kaloulasulasu. When provided specific names, no one could identify if they knew the person.

On today's visit, LPA Valerio contacted Administrator Sera Nakalevu via cell phone. LPA Valerio requested Administrator Sera send all administrator documents via email to cclascpsacramentosouthRO@dss.ca.gov



As a result, 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260211105253
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2026
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties (a)The administrator...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:
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The licensee to submit 40 hour Administrator plan by POC due date.
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Based on observations and interviews, the licensee did not ensure a certified administrator was present in the facility, which poses an immediate health, safety and personal rights risk
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/11/2026 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20260211105253

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:
08/03/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sera NakalevuTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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The facility allowed excluded individuals to work in the facility.
Staff are forging resident documents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with direct care staff, Mere, and explained the purpose of the visit. Facility staff informed person who oversees the facility, Jackee, of LPAs arrival.

The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility.

Allegation: The facility allowed excluded individuals to work in the facility.
On 02/17/2026, LPA Valerio interviewed four (4) residents that were present in the facility. Four (4) out of four (4) interviews informed LPA that they have never seen excluded individual 1 (EI-1) or excluded individual 2 (EI-2) in the facility. LPA Valerio interiewed staff 1 (S1), which informed LPA EI-1 or EI-2 have not been in the facility.
Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
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 5
Control Number 27-AS-20260211105253
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: 08/03/2026
NARRATIVE
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Allegation: Staff are forging resident documents.

LPA Valerio reviewed files for Resident 1 - Resident 4.

LPA Valerio was unable to confirm the validity of the signatures for LIC 602 for R1 and R2.

LPA contacted the number located on R3's LIC 602. LPA was able to confirm that the name of the doctor works at the medical office indicated on the LIC 602.

LPA Valerio reviewed the LIC 602 for R4. R4's LIC 602 is a scanned copy and the signed name on the last page is not legible. LPA unable to confirm or deny the signature is 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5