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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:02:04 PM

Document Has Been Signed on 02/19/2025 04:02 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: 6DATE:
02/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee, Lina TuilomaTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 02/19/2025 Licensing Program Analyst (LPA) Cheyenne Ratajcak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced. LPA and LPM met with Administrator Adi Lina Tuiloma and explained the purpose of the visit. LPA and LPM conducted a case management visit to issue citations in relation to complaint control#: 59-AS-20241120120334

During the complaint investigation, it was found that S1 was not criminally record cleared or associated to this facility at the time the incident occurred. The Administrator admitted that the facility failed to request a criminal clearance association for S1. Additionally, the Licensee failed to report the incident related to the complaint investigation.

During today's case management visit, LPA and LPM toured the facility, conducted interviews and records review. The following deficiencies were found:
1) S2 is a live in staff at this facility. S2 has worked 24 hours a day for the past 14 days without any additional staff assistance. There are currently six (6) resident's residing in the facility. Two (2) are receiving Hospice services and bedridden, one (1) of six (6) residents is diagnosed with Dementia and four (4) of six (6) resident's are non-ambulatory. Based on resident's needs and documentation, the department has determined that this facility does not have sufficient staffing. Based on Title 22, Section 87411(a), the facility shall ensure there are two (2) care staff on duty during all waking hours.

2) During a facility walk through, LPA and LPM found chemicals and toxins in the laundry room unlocked and accessible to resident's in care.

Continued on 809-C
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.

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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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
VISIT DATE: 02/19/2025
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3) A review of resident records found the following
R1) Admission agreement is not signed by resident and/or responsible party
R2) Physician's Report/ LIC602 is not signed by physician

4) The department learned that the facility thermostat was inoperable for several days during November 2024 resulting in the facility not having heat. The licensee failed to report this incident to the department as required.

As a result of todays visit deficiencies cited and civil penalties assessed.

Exit interview conducted and a copy of the report and appeal rights was left at the facility.
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
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/19/2025 04:02 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 02/19/2025 at 03:07 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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Licensee will submit a statement of understanding to LPA Ratajczak that all staff must be fingerprint cleared and/or transferred prior to working in the facility. POC due 02/20/2025
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above due to caregiver not being associated with the facility which poses an immediate health and safety risk to persons in care.
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Type A
02/20/2025
Section Cited
CCR87309(a)

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87309 Storage Space and Access
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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Licensee is to lock laundry room door immediately. Licensee is to conduct a staff training regarding this regulation and submit a copy of who attended the training to LPA. POC due 02/20/2025
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Based on observation, the licensee did not comply with the section cited above due facility laundry room door being unlocked and open making chemicals assessable to 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2025 04:02 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 02/19/2025 at 03:11 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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
CCR
87211(2)

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87211 Reporting Requirements
(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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LPM and LPA went over with Licensee what needs to be reported. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025
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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 due to Administrator not reporting to Community Care Licensing (CCL) when the facility heater was out for two (2) days.
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Type B
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Section Cited
CCR87411(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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License is to have two (2) staff on the floor during waking hours. Licensee is to hire additional staff and send LPA updated LIC500 as well as the new staff facility file.
POC due by 03/05/2025
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This requirement is not met as evidenced by:
Based on interviews and records, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/19/2025 04:02 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 02/19/2025 at 03:14 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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Licensee is to have R1s responsible party sign admission agreement. Licensee is to obtain an updated Physician's Report/ LIC602 for R2 and ensure it is signed by physician. Once completed send a copy of both to LPA. Additionally, the licensee shall submit a plan to the department on how the
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Based on record review the licensee did not comply with the section cited above due two (2) out of six (6) residents files being incomplete with signatures.
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the licensee will ensure resident's records are complete and maintained. POC due 03/05/2025.

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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.
SUPERVISOR'S 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


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