306006554-5-23-2025-22-AS-LMOA-DH72M6-20250530173033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006554
Report Date: 05/23/2025
Date Signed: 05/23/2025 04:52:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/19/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250519120454

FACILITY NAME:	LEGACY SENIOR LIVING 2		FACILITY NUMBER:	306006554
ADMINISTRATOR:	TRAN, HONGLAN		FACILITY TYPE:	740
ADDRESS:	19142 STINGRAY LANE		TELEPHONE:	(714) 249-0176
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92646
CAPACITY:	6	CENSUS: 4	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Licensee Thi Nhu Mai Do		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff restricted resident’s ability to have visitors
Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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On May 23, 2025, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegation. LPA Kim met with Licensee Thi Nhu Mai Do and explained the purpose of the visit.

During today's visit, LPA Kim conducted a physical plant tour inside and outside of the facility with Licensee Do, and no concerns were observed. LPA Kim reviewed R1’s records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans, and other pertinent records. LPA obtained resident roster, staff roster, visitor’s log, and other pertinent records. LPA Kim conducted one (1) resident interview, one (1) witness interview, and two (2) staff interviews.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250519120454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2	FACILITY NUMBER: 306006554
	VISIT DATE: 05/23/2025

NARRATIVE

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Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation Staff restricted resident’s ability to have visitors and Staff did not safeguard resident's personal belongings. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted a copy of the report was provided to Licensee Thi Nhu Mai Do.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250519120454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2	FACILITY NUMBER: 306006554
	VISIT DATE: 05/23/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff restricted resident’s ability to have visitors

During LPA’s interview with the R1 around 9:20 AM, LPA observed resident (R1) kept repeating themselves and having short memory of the conversation. Later in the day around at 11:30 AM, R1 asked LPA if they were going to interview them. R1 did not recall speaking with LPA earlier that day. Based on record review, according to physician’s report dated February 21, 2025, R1 is confused and disoriented.

R1 has a designated POA per review of resident’s Admission Agreement dated March 3,2025 POA instructed the facility through email dated May 12, 2025, not to permit a family member to visit and take resident off the facility for safety reason.

Based on interviews conducted, one resident, two staff, and one witness denied all allegations. Witness #1 (W1) stated on May 16, 2025, Police came to the facility to instruct the family member not to see R1 in the facility and administrator was also informed. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff did not safeguard resident's personal belongings. It is alleged resident’s planner was missing.

Based on interviews conducted, one resident, two staff, and one witness denied this allegation. Witness (W1) stated the POA informed that R1 has two planners and instructed them to take one from R1 to prevent confusion of their daily activities. Staff#1 stated POA instructed the facility to take one planner from R1 in the morning and keep it somewhere safe in the facility and return the planner the next day. During the visit, LPA observed R1 has their two planners with them while sitting at the dining room. LPA confirmed with R1 that those were R1’s planners and they were not missing. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation.

Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

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