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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006276
Report Date: 04/27/2023
Date Signed: 04/27/2023 03:44:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2023 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230419161946
FACILITY NAME:LEGACY SENIOR LIVINGFACILITY NUMBER:
306006276
ADMINISTRATOR:TRAN, HONGLANFACILITY TYPE:
740
ADDRESS:19892 POTOMAC LNTELEPHONE:
(714) 785-9555
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Helen Sartorio, Caregiver, Ban "Jason" Nguyen, LicenseeTIME COMPLETED:
03:42 PM
ALLEGATION(S):
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-Facility failed to issue refund
INVESTIGATION FINDINGS:
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a ten day visit to address the allegation listed above.
LPA Quiroz arrived to facility and met with Caregiver Helen Sartorio. Licensee Ban "Jason" Nguyen arrived shortly after. LPA Quiroz met with Licensee Nguyen and discussed purpose of today's visit. On or about 10:05am, LPA Quiroz along with Licensee Nguyen toured the interior and exterior of the facility premises.
During the course of the investigation, LPA Quiroz conducted interviews with interviewees.
Based on interview with Licensee Nguyen, Resident (R1) was never assessed or admitted to the facility. 4 of 4 interviewees indicated (R1) was never admitted into the facility, and that no written admission agreement was signed. 4 of 4 interviewees indicated $1000 payment via zelle was provided electronically to Licensee on 4/2/2023, and that no receipt or written agreement was provided to (R1) or (R1s) representative. 3 of 4 interviewees indicated Licensee was informed on 4/6/2023 that (R1) would not be moving into Legacy senior Living and would be moving closer to the Family. As of today's date witness has not received a full refund.
CONTINUE...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20230419161946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276
VISIT DATE: 04/27/2023
NARRATIVE
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Based on evidence gathered during this investigation the preponderance of the evidence standard has been met, and therefore the allegation is substantiated. The following deficiency is being cited per Title 22, of the California Code of Regulation. (SEE LIC 809-D)
An exit interview was conducted with Licensee Ban "Jason" Nguyen, and a copy of this report, LIC 811- Confidential names, Appeal Rights and LIC 809-D were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230419161946
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited
CCR
87507(C)(1)
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Admission Agreements 87507(C)(1)Any fee that is charged prior to or after admission, shall be clearly specified.
1.If a licensee charges a preadmission fee, the licensee must provide the applicant or his or her representative with a written general statement
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Licensee Ban "Jason" Nguyen will provide (R1) Representative with $1000 deposit payment via zelle by 4/28/2023 and submit proof of understanding of CCR 87505 to CCL by 4/28/2023.
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describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund. This requirement is not met as evidenced by: On 4/2/2023, (R1) Representative paid Licensee $1000 via zelle payment to hold room for (R1)
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4 of interviewees indicated no written general statement was provided to (R1) or (R1)s representative. This poses a potential risk 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3