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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:31:43 AM

Document Has Been Signed on 12/18/2024 11:31 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/
DIRECTOR:		TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:7084 CANEVALLEY CIRTELEPHONE:
(916) 701-7737
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administraor- Adi Lina TuilomaTIME VISIT/
INSPECTION COMPLETED:
11:35 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 12/18/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPAs met with Administrator, Adi Lina Tuiloma and explained the purpose of the visit.

LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, laundry room, kitchen and the common areas. While on tour LPAs observed two (2) residents residing in a room that is cleared for only one (1) non- ambulatory resident.

LPA conducted a file review of four (4) 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.

CARE inspection tool completed and deficiencies was observed. Please see LIC 809-D. Today's visit, civil penalties assessed.

LPA requested a copy of facility's liability insurance, LIC 500 and LIC 308 by 12/20/24.

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: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 2
Document Has Been Signed on 12/18/2024 11:31 AM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 12/18/2024 at 11:08 AM
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: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents were residing in a room only cleared for one (1) non- ambulatory resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
1
2
3
4
Licensee is to move one of the residents into another room and will send confirmation to LPA once completed. Additionally Licensee will submit a state of understanding of this regulation to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2