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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:40:10 AM


Document Has Been Signed on 12/21/2023 11:40 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:
12/21/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lina (Nina) TuilomaTIME COMPLETED:
11:55 AM
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On 12/21/2023, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility announced to conduct a Pre- Licensing inspection utilizing the pre-inspection tool. LPAs met with Licensee, Lina (Nina) Tuiloma.

LPAs and Licensee conducted a tour of the facility. Areas toured include but are not limited to, two (2) private resident bedrooms, two (2) shared residents bedrooms, two (2) bathrooms, laundry room, caregiver bedroom, kitchen, backyard and the common areas.

All bedrooms had furnishings which include, a bed for each resident, night-stand, lamp, and storage space. Each exit door has a chime that rings whenever door is opened. All sharps and toxins will be stored and locked in the laundry room. Medications will be locked in the kitchen area. Facility has 7+ day of non-perishables.

LPAs observed the facility to have the needed signs posted in the common areas. The facility is at 73 degrees. Two (2) carbon monoxide detectors and six (6) smoke alarms were present in the facility. Fire extinguisher was last checked on 09/06/23.

It was advised Licensee should fix the small hole in the wall in bedroom #5. In bedroom #3 to lower the bed frame as it is too tall for a resident to slide into the bed. As well as to store the knives in the kitchen in a locked cabinet so it will be easily accessible to a caregiver when they are cooking. LPA advised if residents records are centrally stored in the common area, it is to be safeguard to maintain confidentiality.

Comp III completed. No deficiencies observed. LPA Ratajczak will notify CAB of inspection completion.

Exit interview 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: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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