<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 05/15/2024
Date Signed: 05/15/2024 10:59:16 AM


Document Has Been Signed on 05/15/2024 10:59 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: 5DATE:
05/15/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator- Lina TuilomaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/15/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a post- licensing visit utilizing the care tool. LPA met with Administrator, Lina Tuiloma and explained the purpose of the visit. The facility was licensed on/around 12/29/23 for six (6) non-ambulatory residents and has an approved hospice waiver for one (1). Currently, there are five (5) residents and no one receiving hospice services.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: two (2) private resident bedrooms, two (2) shared residents bedrooms, two (2) bathrooms, laundry room, kitchen, backyard and the common areas. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, knives and medications are locked and inaccessible to residents in care. Hot water temperature was measured at 116 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 72 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed required Licensing posters posted throughout the facility.

LPA conducted a file review of two (2) resident files. Residents files contain signed admission agreements, physician reports, Identification sheets, releases, preplacement appraisals, and resident rights. LPA also conducted a file review of two (2) staff files. Staff have training in dementia, first aid and CPR, and other various areas of care provision.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1