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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701616
Report Date: 01/16/2026
Date Signed: 01/16/2026 02:59:18 PM

Document Has Been Signed on 01/16/2026 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIIFACILITY NUMBER:
342701616
ADMINISTRATOR/
DIRECTOR:		KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:9279 ORANGE CREST CT.TELEPHONE:
(916) 701-7737
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/16/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Adi Lina Tuiloma TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On January 16, 2026, Licensing Program Analyst (LPA) Arvin Villanueva arrived at the facility unannounced to conduct a post-licensing inspection and quarterly monitoring visit. LPA met with staff on duty, Mere Faletono (S1), and explained the purpose of the visit.

Upon arrival, there was one staff member on duty (S1). During the visit, there were four residents in care. Later, S2 arrived to assist. According to the Personnel Report (LIC500), Administrator Tevita Kaloulasulasu (AD) was scheduled to work today from 8:00 a.m. to 3:00 p.m.; however, staff reported that AD was working at another facility.

The licensee, Adi Lina Tuiloma (S2), arrived at the facility at approximately 10:45 a.m. Per conversation with Adi, there was a staff call out and she had to take a resident to their appointment. However, Adi did not ensure proper staffing as agreed during a Non-Compliance Conference on September 25, 2025.

LPA conducted a physical inspection of the facility, including resident bedrooms, bathrooms, kitchen, common areas, and outdoor spaces.

LPA also reviewed records for 4 of 6 residents and 4 of 8 staff members based on the LIC500 dated December 1, 2025.




{Con't 809-C}
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/16/2026
NARRATIVE
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The following deficiencies were observed during the visit:
  • The licensee previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Today, only one staff member was present when LPA arrived.
  • In the pantry, LPA observed a box of hygiene wipes stored with food items.
  • In the kitchen refrigerator, LPA observed opened food items without labels or dates.
  • The refrigerator did not have a thermometer, and its temperature could not be determined.
  • The kitchen freezer temperature was 15 degrees Fahrenheit.
  • A can of beer was found in the kitchen freezer, accessible to residents. Staff stated the beer belongs to a resident.
  • LPA observed a couple of red ants in a kitchen drawer near the sink. The licensee stated they use insect spray to address pests.
  • Knives were found in the dishwasher, and two meat thermometers were stored in a kitchen drawer.
  • LPA could not confirm if an incident report for a former resident (R2) dated November 19, 2025, was submitted to the Department.
  • LPA could not confirm if an incident report for resident (R3) dated December 22, 2025, was submitted to the Department.
  • Resident R1 did not have a hospice care plan available for review.
  • The licensee admitted that a hospice initiation notice for R1 was not submitted to the Department when hospice care began.
  • The licensee admitted there is no evidence of staff training related to hospice care for R1, stated there was training but was not documented.

Based on today's visit, deficiencies are being cited. Exit interview was conducted with Adi and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/16/2026 02:59 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/16/2026 at 01:12 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2026
Section Cited
CCR
87205(a)

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The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
This requirement is not met as evidenced by:
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Licensee agreed to submit a written plan to ensure two staff are present at the facility at all times, as agreed upon during NCC meeting. Plan should include times when there is staff call outs and emergencies.
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Per observation, the licensee did not ensure 2 staff are working at the facility at all times, as agreed upon during NCC meeting. This poses a potential health, safetly, and personal rights risks to persons in care.
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Plan to be submitted to the Department by POC due date.
Type B
01/23/2026
Section Cited
CCR87555(b)(25)

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Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
This requirement is not met as evidenced by:
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Corrected on site: staff removed the hygeine wipes and stored them in a different storage away from food items.
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Based on observation, LPA found hygiene wipes stored in the pantry with food items. This poses a potential health, safetly, and personal rights risks to persons in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2026 02:59 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/16/2026 at 01:49 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2026
Section Cited
CCR
87555(b)(9)

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Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
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Licensee agreed to submit a written plan for proper food storage. Per licensee, she will conduct staff training. Submit plan and proof of training to the Department by POC due date.
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Based on observation, LPA observed some open food items in the kitchen refrigerator and freezer without lable and dates. This poses a potential health, safety and personal rights risks to persons in care.
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Type B
01/23/2026
Section Cited
CCR87555(b)(27)

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All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
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Licensee agreed to obtain a pest control service and submit contract to the Department by POC due date.
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Based on observation of the kitchen area, LPA observed red ants in one of the kitchen drawer and licensee do not have pest control service at this time. This poses a potential health, safety and personal rights risks to persons in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/16/2026 02:59 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/16/2026 at 01:57 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2026
Section Cited
CCR
87309(a)

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the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage. This requirement is not met as evidenced by:
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Corrected on site: staff immediately stored the sharp objects in locked drawer.
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Based on observation, 2 kitchen knives were observed in the dishwasher and 2 meat thermometers were observed in a kitchen drawer. This poses an immediate health, safety and personal rights risks to persons in care.
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Type B
01/23/2026
Section Cited
CCR87633(b)

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: A current and complete hospice care plan shall be maintained in the facility for each hospice resident.
This requirement is not met as evidenced by:
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Licensee agreed to obtain a copy of R1's hospice care plan and submit plan to the Department by POC due date.
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Per record review and interviews, hospice care plan for R1 was not available for review during this visit. This poses a potential health, safety and personal rights risks to persons in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
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