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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920063
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:33:48 AM

Document Has Been Signed on 03/11/2025 11:33 AM - 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:
03/11/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Mosese DelaiTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On 03/11/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak and Cassandra Mikkelson arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding the deficiencies LPA cited the facility on 02/19/2025 during a case management visit. LPAs met with Staff Mosese Delai and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist and sign the report during today's visit.

While on the phone with the Administrator LPA explained that failure to correct plan of correction by the given due date could and will result to $100 per day civil penalty until corrected.

On 02/19/2025, LPA cited the facility on CCR 87211(2) and Licensee agreed upon a POC Due Date of 03/05/2025 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. Licensee did not ensure that the POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected.

On 02/19/2025, LPA cited the facility on CCR 87411(a) and Licensee agreed upon a POC Due Date of 03/05/2025 License is to have two (2) staff on the floor during waking hours. Licensee is to hire additional staff and send LPA updated LIC500 as well as the new staff facility file. Licensee did not ensure that the POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected.

Please continue to LIC809C....
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
VISIT DATE: 03/11/2025
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On 02/19/2025, LPA cited the facility on CCR 87411(a) and Licensee agreed upon a POC Due Date of 03/05/2025. Licensee is to have R1s responsible party sign admission agreement. Licensee is to obtain an updated Physician's Report/ LIC602 for R2 and ensure it is signed by physician. Once completed send a copy of both to LPA. The licensee shall submit a plan to the department on how the Licensee did not ensure that the licensee will ensure resident's records are complete and maintained. POC due 03/05/2025. POC was corrected upon Due Date of 03/05/2025. LPA will be assessing a Civil Penalty of $100/day from 03/06/2025 to 03/11/2025 for this violation and will continue to accrue until POC is corrected.

Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date.

Exit Interview was conducted. A copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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