<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920063
Report Date: 05/13/2026
Date Signed: 05/13/2026 02:38:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2026 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20260401135846
FACILITY NAME:LEGACY SENIOR CAREFACILITY NUMBER:
345920063
ADMINISTRATOR:TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:7084 CANEVALLEY CIRTELEPHONE:
(916) 701-7737
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 6DATE:
05/13/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jokaveti Tubuna, Care StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not preventing a resident from wandering away from facility
Staff are not adequately supervising resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensed Program Analyst (LPA) Bethany Mirlohi arrived at the facility unannounced and met with Jokaveti Tubuna to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

*** Report continued on 9099-C***


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20260401135846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
VISIT DATE: 05/13/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff are not preventing a resident from wandering away from facility

Records reviewed indicated that Resident R1 was unable to leave the facility unattended. R1 enjoyed taking walks outdoors and would be accompanied by a staff member. On 03/26/2026, R1 turned off the front door alarm, which staff were aware R1 was able to do, and walked out the front door to stand in the driveway. Staff were only alerted that R1 left the facility when a neighbor saw R1 standing in the driveway and brought R1 back inside. Interviews conducted indicated that staff were “on-call” and sleeping as facility does not require wake staff at night. Staff S1 was made aware of R1 leaving the premises when a neighbor brought R1 back inside the facility early morning on 3/26/2026.

Therefore, the allegation staff are not preventing a resident from wandering away from facility is substantiated.

Staff are not adequately supervising resident in care

Interviews conducted with administrator and staff member S1 indicated that Resident R1 was a wandering risk. Staff would take R1 on walks around the neighborhood but sometimes R1 would try to leave the facility unassisted by turning off the front door alarm and walking outside. Staff were aware the R1 had wandering tendencies and knew that R1 had attempted to elope prior to the incident on 3/26/2026. Records reviewed indicated that R1 was unable to leave the facility unsupervised. Therefore, the allegation staff are not adequately supervising resident in care is substantiated.

Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20260401135846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY SENIOR CARE
FACILITY NUMBER: 345920063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2026
Section Cited
CCR
87463(a)(b)
1
2
3
4
5
6
7
87463 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.(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident
1
2
3
4
5
6
7
Administrator agrees to conduct a training for all staff concerning resident elopement. Administrator to send to LPA the date of training that will take place for the staff by 5/14/26. Once training takes place, administrator to send into CCL a copy of the training.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews and record review the licensee did not meet the needs of resident which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
05/14/2026
Section Cited
CCR
87461(a)(b)
1
2
3
4
5
6
7
87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; (2) is confused or forgetful;
1
2
3
4
5
6
7
Administrator agrees to submit a plan into CCL on how staff will supervisor and redirect residents that are an elopement risk. Plan to be submitted into CCL by 5/14/26.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviewed and record review the licensee did not provide sufficient supervision which poses an immediate health , safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3