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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701616
Report Date: 02/09/2026
Date Signed: 02/09/2026 02:57:36 PM

Document Has Been Signed on 02/09/2026 02:57 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: 3DATE:
02/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Adi Lina Tuiloma TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio was at the facility on a subsequent visit for a complaint visit (Control Number 27-AS-20260209110822). Upon arrival, LPA Valerio rang the door bell twice and knocked on the door twice, but there was no answer. LPA Valerio contacted Licensee Adi Lina Tuiloma via cell phone who contacted staff on shift. Staff stated they were in the restroom when LPA was at the door. LPA Valerio was met by facility staff Mere. LPA Valerio informed Licensee the purpose of the visit. Licensee stated she was assisting with an appointment and thirty minutes away. LPA informed Licensee LPA will wait for her arrival. LPA was later met by Licensee.

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. LPA Valerio observed one staff, Staff 1 (S1) on shift. According to an interview with staff, the second staff (S2) will arrive at 7:00 PM. Later, LPA Valerio interviewed Licensee Adi Lina. Licensee stated S2 is currently an on-call staff and not a regular staff. LPA Valerio reviewed the facility LIC 500, which is dated 12/01/2025. According the LIC 500, S2 was to be on shift with S1. Licensee stated the second staff member was supposed to be her; however, she had to assist with an appointment for her other licensed facility. LPA Valerio was provided an updated LIC 500 by Licensee Adi Lina during today's visit.

Per California Code of Regulations (CCR), Title 22, a deficiency is being cited on the attach LIC 809 - D page. Licensee was previously cited on January 16, 2026 for having only one staff on shift. Due to the repeat violation, licensee was made aware that a civil penalty of $1000.00 will be assessed on today's date of February 9, 2026. Appeal Rights were provided. An exit interview was held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2026
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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Document Has Been Signed on 02/09/2026 02:57 PM - It Cannot Be Edited


Created By: Christina Valerio On 02/09/2026 at 02:36 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: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2026
Section Cited
CCR
87205(a)

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87205 Accountability of Licensee Governing Body The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility ...This requirement is not met as evidenced by:
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Licensee stated she would submit an updated LIC 500, which was collected during today's visit. Licensee stated she would send LPA copies of the employee packet for the new hire, which would be the second staff on shift. LPA to receive documents by POC due date
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Based on LPA 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, 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:
Christina Valerio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2026


LIC809 (FAS) - (06/04)
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