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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 12/13/2023
Date Signed: 12/21/2023 11:39:30 AM


Document Has Been Signed on 12/21/2023 11:39 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 0DATE:
12/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Adi Lina (Nina) TuilomaTIME COMPLETED:
10:10 AM
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On 12/13/23, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to conduct a Prelicensing inspection. LPA and LPM met with Licensee, Nina Tuiloma and explained the purpose of this visit.

This facility is currently under change of ownership and there are zero (0) resident residing.

LPA and LPM observed the facility to be in the process of being cleaned out and organized. Licensee stated they are still in the process of getting the facility ready for residents.

Licensee stated that they need more time to get the facility ready, but should be ready by end of this week. LPA and Licensee are going to schedule a pre licensing visit for next week.

On 12/21/2023, exit interview was conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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