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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920063
Report Date: 08/05/2025
Date Signed: 08/05/2025 11:17:57 AM

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
03/24/2025 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20250324140656
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:
08/05/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Dillon WilliamsTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff mishandled a resident's medication while in care
INVESTIGATION FINDINGS:
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On 08/05/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings to a complaint Community Care Licensing (CCL) received on 03/24/2025. LPA met with Staff Dillon Williams and explained the purpose of the visit. Staff notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist LPA during today's visit.


During the course of the investigation, the Department conducted interviews and record reviewed.


Please continue to LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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-20250324140656
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: 08/05/2025
NARRATIVE
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Allegation: Staff mishandled a resident's medication while in care

The department conducted a medication audit of six (6) resident’s medications. The results are as follows:

Resident #1 (R1) was prescribed Ascorbic acid and Zinc Sulfate which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma who indicated it may need to be reordered.

Resident #2 (R2) was prescribed ChlordiazePOXIDE, nitrofurantoin, and thiamine which were not present in the facility. Additionally, based on the facility Medication Administration Record (MAR) for R2, facility staff administered R2 Naltrexone 50MG however there were no orders for the Naltrexone on R2’s recent medication list.

Resident #3 (R3) was prescribed Ascorbic Acid, Lidocaine, Melatonin, Multivitamins & minerals, NovoLOG FlexPen and Zinc Oxide, which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma and asked where R3’s medications were. The Administrator stated they were unsure.

Resident #4 (R4) was prescribed Acetaminophen-rectal suppository and Morphine Sulfate, both of which were not present in the facility.

Resident #5 (R5) was prescribed Cephalexin 500mg, clobetasol 0.05%, ergocalciferol 1,250 mcg, FeroSul 325mg, mupirocin 2%, nystatin 100,00 unit/gram ointment, nystatin 100,000 unit/gram powder, risperidone 0.5 mg, sennosides-docusate sodium 8.6, thiamine 100 mg, vitamin D3- vitamin K2 (MK4) which were not present in the facility. Additionally, Hibiclens 4% Liquid was with R5s medications but not list on R5s medication list. LPA reviewed facility Medication Administration Record (MAR) and did not observe the medication as being given to R5. LPA asked Staff who stated it came with R5 from the skilled nursing facility. The facility has not used the Hibiclens 4% Liquid on R5.

Resident #6 (R6) was prescribed Fluoxetine 40mg which was not present in the facility.


Based on LPAs medication audit and interviews, the facility did not ensure that staff did not give residents their medication as prescribed. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D

As a result of today's visit deficiencies are cited.

Exit interview conducted a copy of the report and appeal rights were left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250324140656
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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2025
Section Cited
CCR
87465(a)(4)
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87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.

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The Licensee shall conduct the following:
1. Obtain updated medications orders for all resident’s in care
2. Compare medications present in the facility with resident’s medication orders
3. Order any medications prescribed to residents that are not present in the facility
4. If there are any medications in the facility that have been discontinued, the licensee shall obtain discontinue orders from physician and follow medication destruction regulations
5. Submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training
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This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.
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The licensee shall submit all resident current medication orders and discontinued orders by POC date (24 hours). The licensee shall submit plan by (2 weeks).
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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: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3