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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 03/03/2025
Date Signed: 03/03/2025 02:06:57 PM

Document Has Been Signed on 03/03/2025 02:06 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
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: 6DATE:
03/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Adi Lina Tuiloma TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 03/03/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit to follow up on the incident report the department received on 02/28/2025. LPA met with Administrator, Adi Lina Tuiloma, and explained the purpose of the visit.

LPA and Administrator discussed the incident which occurred on 02/21/2025 regarding an electrical fire which happened in the hallway bathroom. The fire happened in the evening on 02/21/2025 around 7:30 p.m. There was six (6) residents and one (1) staff present. Staff #1(S1) stated the facility smoke alarms went off. S1 assessed rooms and residents and saw the smoke coming out of the bathroom. S1 was able to put the fire out. Once fire was out S1 called emergency services to come out and assess the area. Local emergency services told the facility to not use the bathroom until the wires were fixed.

On 02/22/2025 the facility did have an electrician come out to assess all the wires in the facility. Administrator stated it was just that one wire and it was fixed the same day as the visit from the electrician. The bathroom is in working condition and residents are able to use it again.

LPA and Administrator discussed that incidents need to be reported to Community Care Licensing (CCL) within 24 hours of occurrence.

As a result of todays visit deficiencies cited.


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: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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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Document Has Been Signed on 03/03/2025 02:06 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 03/03/2025 at 12:05 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
CCR
87211(2)

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87211 Reporting Requirements
(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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LPA went over with Licensee the reporting timeframe. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) winthin 24 hours of the facility having a fire
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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.
SUPERVISOR'S NAME:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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