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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920063
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:47:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
11/20/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20241120120334
FACILITY NAME:LEGACY SENIOR CAREFACILITY NUMBER:
345920063
ADMINISTRATOR:TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:7084 CANEVALLEY CIRTELEPHONE:
(916) 701-7737
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 6DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Lina TuilomaTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff left residents unattended at the facility
INVESTIGATION FINDINGS:
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On 02/19/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Licesning Program Manager (LPM) Laura Munoz arrived at the facility unannounced to deliver final findings for a complaint Community Care Licensing (CCL) received on 11/20/2024. LPA and LPM met with Administrator Lina Tuiloma and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099C..



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 3
Control Number 59-AS-20241120120334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
VISIT DATE: 02/19/2025
NARRATIVE
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Allegation: Staff left residents unattended at the facility

Interviews conducted revealed that on 11/18/2024, S1 left the facility leaving no staff on the premises to care for the residents. S1 had left the facility sometime throughout the night. During interview, R1 stated that S1 had come into their room sometime throughout the night and stated that they will be leaving. R1 stated they went back to sleep and thought it was just a dream. When R1 and the other residents woke up in the morning of 11/18/2024, they found no staff present in the facility and attempted to make their own breakfast noting they were hungry. Interviews indicated R1 called their family in the morning of 11/18/2024 to notify that there were no staff present in the facility. Administrator stated they were unaware residents were left unattended until a R1's family member called and stated that there was no care staff at the facility. Administrator stated that they were notified around 9:30 a.m. and showed up to the facility at 10 a.m.

An interview with S1 confirmed that S1 did leave the facility stating they were not feeling well and needed medical attention. When asked if S1 contacted Administrator, S1 stated they called and left a voicemail message.

Administrator additionally stated that the staff has not been back at the facility since the incident.

Based on interviews conducted by the department, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited on the attached 9099-D page.

As a result of resident's being left without supervision, civil penalties are assessed in the amount of $500.

Exit interview conducted and a copy of the report and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20241120120334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee is to conduct a training with staff regarding supervision as well as submit a LIC500 with back up staff. POC due by 02/20/2025





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This requirement is not met as evidenced by:
Based on interviews the licensee did not comply with the section cited above as staff had left the facility and residents were left unattended.
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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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3