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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881237
Report Date: 03/11/2026
Date Signed: 03/11/2026 12:09:52 PM

Document Has Been Signed on 03/11/2026 12:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OUR LEGACY LLCFACILITY NUMBER:
331881237
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, JEANNETTEFACILITY TYPE:
740
ADDRESS:13000 WILD SAGE LNTELEPHONE:
(951) 575-7775
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 6DATE:
03/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Administrator, Jeannette RodriguezTIME VISIT/
INSPECTION COMPLETED:
12:08 PM
NARRATIVE
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On March 11, 2026, Licensing Program Analyst (LPA), Jarred Torres, and LPA Mia Lankford, arrived at the facility unannounced to conduct an annual inspection and met with Administrator, Jeannette Rodriguez. A facility file review was conducted at the regional office and additional records were requested and reviewed at the facility. Their files were stored in a secure location. The facility is licensed for six elders and was operating at a capacity of six elders.

The LPAs toured the facility along with the Administrator and made observations pertaining to the annual inspection. The LPAs inspected the facility inside and outside. There were no obstructions on the indoor and outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises.

During the tour of the premises, the LPAs observed the facility phone to be operable. The facility's phone number is 951-221-1563. The LPAs observed the residents' bedrooms which were equipped with the required furniture as stated in Tittle 22 of the California Code of Regulations (CCR); however, bedroom two and bedroom six had broken drawers that were askew and did not function properly. This issue was discussed with the Administrator and a deficiency and plan of correction were issued. The furniture in all other areas of the facility was observed to be in good condition. The facility's appliances were observed to be operational at the time of this visit. The facility is equipped with operational smoke detectors and a carbon monoxide detector. The fire extinguishers were in good condition and were serviced on January 2, 2026. Required postings regarding safety, personal rights, and emergency exits were posted in the home. The cleaning supplies were not kept locked and inaccessible to clients in care, so a deficiency and a plan of correction was discussed with the Administrator and issued. Sharp items were kept locked and inaccessible to residents in care. Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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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Document Has Been Signed on 03/11/2026 12:09 PM - It Cannot Be Edited


Created By: Jarred Torres On 03/11/2026 at 10:50 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OUR LEGACY LLC
FACILITY NUMBER: 331881237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

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 one incident which required an unusual incident report to be submitted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Administrator will train staff on reporting requirements, submit an unusual incident report for the incident that required a report to be submitted, and they will submit proof via e-mail to Licending Program Analyst, Jarred Torres.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in two out of five bedrooms that had broken drawers, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Administrator will contact the handyman to fix the drawers. The Administrator will send proof of the repair request via e-mail to Licensing Program Analyst, Jarres Torres' e-mail.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/11/2026 12:09 PM - It Cannot Be Edited


Created By: Jarred Torres On 03/11/2026 at 10:50 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OUR LEGACY LLC
FACILITY NUMBER: 331881237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one out of one kitchens where cleaning supplies were not locked and inaccessible to clients in care, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
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In the presence of the LPAs, the administrator moved cleaning supplies and chemicals to a secured and locked location which is inaccessible to clients in care.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 two out of seven client files where a health screening was missing, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Administrator will remove staff from schedule until a health screening is completed. Administrator will send proof via e-mail to Licensing Program Analyst, Jarred Torres.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OUR LEGACY LLC
FACILITY NUMBER: 331881237
VISIT DATE: 03/11/2026
NARRATIVE
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The facility's cooling and heating system is operational and the air temperature was at 73 degrees Fahrenheit(F) and the hot water was measured at 118.

The LPA observed the medications to be locked and inaccessible to clients in care. The medication supply was sufficient for the six clients in care. There were no discrepancies with the centrally stored medications and Medication Administration Records.

In the kitchen, the food supply of non-perishable and perishable foods consisted of, but not limited to, bread, eggs, frozen meats, vegetables, juice, water, and fruits. The facility goes grocery shopping two times per week and maintains an appropriate food supply for the six clients in care.

Adequate staff was present for the supervision of the residents in care. The facility has a designated area for storing activity supplies and activities are conducted in the living room and backyard. Telephone numbers and floor plans were posted in the facility. The Administrator showed proof that they resubmitted payment to the Department, and their administrator's certificate is pending renewal. This proof was sent to LPA Torres' e-mail.

Client files and staff files were reviewed. During the staff file review, the LPAs observed that two out of seven staff did not have the required health screening. This issue was discussed with the Administrator and a deficiency with a plan of correction was issued. No discrepancies were observed during the review of client files.

The LPA reviewed the emergency disaster plan and fire clearance. The next emergency drill will be conducted on March 12, 2026. The emergency disaster plan meets the department's standards.

The LPA inspected the bathrooms and observed the hand washing stations to have the required non-medicated soaps and single-use hand towels. Furthermore, the bathrooms are free of dust and debris. Additionally, the facility has an approved infection control plan in their files.

An exit interview was conducted and this report was reviewed with the Administrator. A copy of this report, LIC 809-Ds, and appeal rights were provided to the Administrator whose signature confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
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