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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920084
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:17:37 PM

Document Has Been Signed on 05/02/2024 02:17 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 CARE IIFACILITY NUMBER:
345920084
ADMINISTRATOR/
DIRECTOR:		TUILOMA, ADI LINAFACILITY TYPE:
740
ADDRESS:3624 OWENS WAYTELEPHONE:
(916) 701-7737
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 5DATE:
05/02/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:52 PM
MET WITH:Walesi Vakararawai, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On May 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a post-licensing visit. LPA met with Walesi Vakarawai
caregiver and informed her the reason for the visit.

During the last visit, LPA noticed the washer and dryer was not placed in the area it is supposed to go. LPA informed the administrator that LPA would be back to see if it was in the area it is supposed to be. When LPA arrived a caregiver allowed entry into the home. LPA noticed the washer and dryer was in fact in the area it is supposed to be. LPA asked the caregiver how it was going and did they need anything. Caregiver said everything was going well and had no questions. The facility now has 5 residents living in the home. No known issues.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy of this report was given to Walesi.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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