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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 10/14/2025
Date Signed: 10/14/2025 02:06:14 PM

Document Has Been Signed on 10/14/2025 02:06 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY SENIOR CAREFACILITY NUMBER:
345920063
ADMINISTRATOR/
DIRECTOR:		TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:7084 CANEVALLEY CIRTELEPHONE:
(916) 701-7737
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 5DATE:
10/14/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Mereisis Naisausau & Adi Lina Tuiloma TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/14/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit. LPA met with staff, Mereisis Naisausau and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator later arrived at the facility.

During today's visit, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Storage space was inspected to confirm medications, toxins and sharps are locked and secured.

LPA conducted a medication audit of three (3) residents.
Resident #1 (R1) was prescribed Fluoxetine (40mg), Cyclobenzaprine (5mg) and Oxycodone (5mg) which were not present in the facility. Administrator said they will reach out to R1s doctor.
Resident #2 (R2) was prescribed Clobetasol 0.05% ointment, Mupirocin 2% ointment and Terbinafine 250mg tablet which were not present in the facility. Administrator said they will reach out to R2s doctor.
Resident #3 (R3) was prescribed Doxycycline 100 mg tablet and Levetriacetam 100 mg/ml solution which were not present in the facility. Administrator said they will reach out to R3s doctor.

LPA conducted a file review of residents. All resident files contained required documents. Three (3) out of five (5) residents are non- ambulatory and require full or partial assistances with ADLs. One (1) resident is on hospice. One (1) resident requires a hoyer lift. Administrator stated that facility staff do not use the hoyer lift for R4. It is used for when transportation comes to take the resident to appointments.

As a result of today's visit, deficiencies observed. Please see LIC 809-D.

Copy of report and appeal rights provided during exit interview.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Cheyenne Ratajczak
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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 10/14/2025 02:06 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 10/14/2025 at 01:20 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
FACILITY NUMBER: 345920063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
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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Licensee is to submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training. Additionally, Licensee will reach out to R1, R2, R3 doctors for updated medication list. Due by POC due date
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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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Type A
10/15/2025
Section Cited
CCR87405(d)(2)

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87405Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Licensee is to submit a plan on how they will ensure all Administrative duties are completed in a timely manner. By POC due date.
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This requirement is not met as evidenced by:
Based on medication audit and interviews facility did not comply to the section cited above as Administrator did not ensure medications are given as prescribed, which poses a immediate health and safety risk for residents 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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Cheyenne Ratajczak
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2025 02:06 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 10/14/2025 at 01:40 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
FACILITY NUMBER: 345920063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2025
Section Cited
CCR
87411(a)

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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee is to have two (2) staff by 11/01/2025 and submit an updated LIC500 reflecting at least of two (2) caregivers minimum working at the facility during waking hours of 7 a.m - 7 p.m including the weekends and one (1) caregiver at night shift.

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This requirement is not met as evidenced by:
Based on records reviewed, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.
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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.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Cheyenne Ratajczak
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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