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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006276
Report Date: 03/18/2026
Date Signed: 03/18/2026 05:03:54 PM

Document Has Been Signed on 03/18/2026 05:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LEGACY SENIOR LIVINGFACILITY NUMBER:
306006276
ADMINISTRATOR/
DIRECTOR:		TRAN, HONGLANFACILITY TYPE:
740
ADDRESS:19892 POTOMAC LNTELEPHONE:
(714) 785-9555
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 4DATE:
03/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Caregiver- Alfredo OrdonaTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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On March 18, 2026, 12:15 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Alfredo Ordona. LPA Kim spoke with Administrator (ADMIN) Ban Nguyen over the telephone and explained the purpose of the visit. ADMIN Nguyen stated they could not attend today’s visit and CG Ordona could sign in behalf of the facility..

The facility is licensed to operate for six (6) nonambulatory residents of which one (1) may be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, outdoor covered patio in the backyard, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant. There were no obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be clean and operational. The water temperature measured between 122.0 degrees F to 125.0 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, toxins, and sharps objects were stored and not accessible to residents.
Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276
VISIT DATE: 03/18/2026
NARRATIVE
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The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted on the wall next to the entrance. It was last serviced on December 3, 2024.

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable except the resident hallway was missing a smoke detector and the shared resident room next to the living area did not have a battery in the detector. The facility did not have a battery to place one in the smoke detector missing the battery. A working telephone (714-916-0629) remains available. Last emergency drill was conducted on March 15, 2026 and is conducted monthly. First aid kit is maintained and contains all the necessary elements. Evidence of Liability Insurance is effective March 22, 2025, and expires March 22, 2026. The facility also provided the insurance that is effective March 22, 2026, and expires on March 22, 2027.

LPA Kim conducted an audit of resident files (R1-R4), staff files (S1-S6), and medication and medication administration record. R1’s last appraisal needs and service plan was on January 13, 2023, R2’s last appraisal needs and service plan was on January 13, 2023, and R3’s pre-appraisal was not completed. LPA Kim conducted interviews with one resident and two staff.

Deficiencies were cited during this visit per Title 22 Division 6 Chapter 8. LPA observed resident bathrooms hot water temperature measured between 122.0 degrees F to 125.0 degrees F. During the visit, the facility adjusted the water temperature and LPA Kim observed the resident bathrooms hot water temperature measured between 116.0 Degrees F to 118.0 Degrees F. LPA observed smoke detectors were missing in the hallway and the shared resident room next to the living area. LPA observe R1’s and R2’s last appraisal needs and service plan was from January 13, 2023 and R3’s pre-appraisal was not completed.

An exit interview was conducted, and a copy of this report, LIC809D, LIC421FC, and appeal rights were provided to Caregiver Alfredo Ordona.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/18/2026 05:03 PM - It Cannot Be Edited


Created By: Edward Kim On 03/18/2026 at 03:46 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident bathrooms hot water temperature measured between 122.0 degrees F to 125.0 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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POC cleared during the visit. The facility adjusted the water temperature and LPA observed the resident bathroom hot water temperature measured between 116.0 degrees F and 118.0 degrees F.
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed the resident hallway smoke detector was missing and shared resident room next to the living room smoke detector was missing a battery. LPA observed the fire extinguisher mounted by the entrance has not been serviced since December 3, 2024. This is an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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Licensee stated they will replace the smoke detectors in the resident hallway and the resident room next to the living room, and replace the fire extinguisher mounted next to the entrance. Licensee stated they will send a photo and video of the replaced smoke detectors and fire extinguisher to CCLD via email to edward.kim@dss.ca.gov by POC due date March 19, 2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/18/2026 05:03 PM - It Cannot Be Edited


Created By: Edward Kim On 03/18/2026 at 03:46 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING
FACILITY NUMBER: 306006276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of four resident appraisal needs and service plan. LPA observed R1's appraisal needs and service dated January 13, 2023, R2's appraisal needs and service dated January 13, 2023, and R3 did not have a completed pre-appraisal needs and service plan. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee states they will complete appraisal needs and service plans for R1, R2, and R3, and send proof of completed Appraisals Needs and Service Plans to CCLD via email to edward.kim@dss.ca.gov by POC due date March 27, 2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
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