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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701616
Report Date: 03/10/2026
Date Signed: 03/10/2026 12:13:10 PM

Document Has Been Signed on 03/10/2026 12:13 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: 4DATE:
03/10/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Adi Lina TuilomaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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An Office Meeting was held on March 10, 2026, at 10:00 AM via Microsoft TEAMS. Present were Licensing Program Manager Stephen Richardson (LPM), Licensing Program Analysts Christina Valerio, Reza Jamaly and Arvin Villanueva (LPAs), and Licensee, Adi Lina Tuiloma. The purpose of this meeting was to discuss facility’s failure to provide requested documentation, including staff timesheets for Administrator, Tevita Kaloulasulasu, and to address additional concerns regarding staffing expectations, payroll practices and documentation retention.

Failure to provide requested documentation:

It was discussed with Adi Lina the facility’s failure to provide requested documentation following an initial request made on February 9, 2026 for staff timesheets and documentation that provide proof of Administrator’s actual work hours. Despite multiple follow-ups, the requested documents had not provided within a reasonable timeframe. Per last office meeting on February 26, 2026, Adi Lina had stated she will have these documents submitted to the Department by March 2, 2026. An email reminder was sent to Adi Lina on Mach 4, 2026 but she did not respond. Adi Lina stated that she had received some recent timesheets but was still waiting for timesheets from September 2025 and October 2025.

Per Adi Lina, the timesheets are typically completed by employees as hard copies when they work on their scheduled shift and are maintained in a file at the facility. However, Adi Lina stated that the hard copies for the Administrator could not be located.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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: 03/10/2026
NARRATIVE
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The Department had concerns regarding the facility’s ability to maintain and produce documentation when requested by the Department. Adi Lina was informed that, as a licensee of the facility, she holds ultimate responsibility for facility operations, including maintaining staff records and ensuring that required documentation can be produced in a timely manner. A delay of one month would not be considered timely.

It was also discussed to Adi Lina the importance of communication with the Department. Adi Lina was informed that if there are any barriers to providing requested documents, as a licensee, she is expected to communicate timely with the LPA and can request an extension. Adi Lina failed to respond to emails timely.

Regarding administrator and payroll:

Adi Lina stated that Tevita Kaloulasulasu has continuously served as the facility’s administrator since it was licensed. Adi Lina stated that Tevita is paid in cash and that no W-2 forms have been issued to him. Adi Lina stated that she has been paying him directly in cash without withholding taxes.

Staffing concerns:

It was discussed that prior visits to the facility, the facility appeared to have only one staff on duty during these visits, despite the requirement for two staff, based on the NCC meeting held on September 25, 2026. Adi Lina stated that she has experienced difficulties retaining staff and that some employees have walked off or called sick. Adi Lina stated that when this occurs, she goes to the facility and serve as a second staff.

Administrator work schedule:

Adi Lina stated that Tevita is scheduled at this facility on Mondays, Wednesdays, and Fridays from 7am to 7pm. Adi Lina explained that Tevita is expected to be at this facility during scheduled time, unless there is a change and Tevita will come the following day.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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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: 03/10/2026
NARRATIVE
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The licensee agreed to the following:
  • Adi Lina will submit all available timesheets for Tevita by close of business day today.
  • Adi Lina will provide the remaining timesheets for September and October by Friday, March 13, 2026.
  • Adi Lina will submit a written plan outlining how the facility will improve documentation retention and accessibility, including procedures to ensure that requested documents can be produce in a timely manner.
  • Adi Lina will submit an updated LIC500 Personnel Reports for each facility operated by her, identifying the staff currently assigned to each facility.
  • Adi Lina will ensure the facility maintains two staffing ratio in accordance with the NCC meeting.

The Department will do the following:
  • The Department will continue to conduct quarterly monitoring visits to this facility.
  • Adi Lina was informed that failure to comply with documentation requests and staffing requirements may result in further enforcement action.

Based on today’s meeting, deficiencies are being cited.

Exit interview was conducted with Adi Lina, who acknowledged the discussion and the expectations outlined above. A copy of this report and appeal rights were provided via email with a request for signature and confirmation of read receipt.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2026 12:13 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/10/2026 at 11:49 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2026
Section Cited
CCR
87755(c)

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Inspection Authority of the Licensing Agency: The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours
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Per disucsison, licensee Adi Lina agreed to submit a written plan outlining how the facility will improve documentation retention and accessibility, including procedures to ensure that requested documents can be produce in a timely manner.
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This requirement is not met as evidenced by:
Based on interviews, the licensee has not provided the requested records as of today, after several attempts to request these records for a period of approximately one month. This poses a potential health, safety, and personal risks to persons in care.
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Plan must be submitted by POC due date.

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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: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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