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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920084
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:45:07 AM

Document Has Been Signed on 03/19/2024 10:45 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 CARE IIFACILITY NUMBER:
345920084
ADMINISTRATOR:TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:3624 OWENS WAYTELEPHONE:
(916) 701-7737
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 0DATE:
03/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelina Tuioma, AdministratorTIME COMPLETED:
11:00 AM
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,On March 19, 2024, at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived announced to conduct a Pre-licensing inspection. LPA met with Angelina, the administrator and informed her the reason for the visit. The administrator's certificate is valid and expires 2/18/2025. The home was 65 degrees F. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to ensure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 107 degrees F. There’s appropriate lighting throughout the facility.

Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 6 Bedrooms and 2 bathrooms for residents. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. First aid kit was present and included the required scissors, tweezers, thermometer and guide.

To continue see 809-C..

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 II
FACILITY NUMBER: 345920084
VISIT DATE: 03/19/2024
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.Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. was not present. Toxic substances, laundry and cleaning supplies are inaccessible. There’s a centralized storage area for resident’s medication. Medication cabinet was locked.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit

An exit interview was conducted and a copy of this report was given to Angelina.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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