345920084-9-25-2025-59-AS-CYAG-DLUQSF-20250925122524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345920084
Report Date: 09/25/2025
Date Signed: 09/25/2025 01:21:50 PM

Document Has Been Signed on 09/25/2025 01:21 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 II		FACILITY NUMBER:	345920084
ADMINISTRATOR/ DIRECTOR:	TUILOMA, ADI LINA		FACILITY TYPE:	740
ADDRESS:	3624 OWENS WAY		TELEPHONE:	(916) 999-0140
CITY:	NORTH HIGHLANDS	STATE: CA	ZIP CODE:	95660
CAPACITY: 6		CENSUS: 6	DATE:	09/25/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Adi Lina Tuiloma and Una Phyllis		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

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A Non-Compliance Conference office meeting was held on September 25, 2025, at Sacramento Regional Office with the Licensee Adi Lina Tuiloma and facility representative Una Phyllis to discuss the deficiencies found at the facility and the actions needed to bring the facility into compliance with Title 22 regulations.

Present in the meeting were Community Care Licensing (CCL) staff, including Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Manager Laura Munoz, Licensing Program Manager Stephen Richardson, Licensing Program Analyst Cassie Yang, Licensing Program Analyst Cheyenne Ratajczak and Licensing Program Analyst Christina Valerio.

During the meeting, CCL reviewed the facility’s history of citations, including Type A and Type B violations since April 2025. The citations involved issues such as fire safety, reporting requirements, resident records, administrator oversight, and reporting requirements. CCL stressed the importance of taking immediate corrective action to ensure resident safety and meet licensing requirements. CCL expressed concern about limited administrator oversight, including the administrator’s low on-site hours, unresponsiveness to calls, and insufficient supervision of staff. Staffing levels were also noted as a concern, with coverage gaps that could put residents at risk.

The licensee agreed to take specific steps to fix these issues. These actions include making sure resident rooms meet licensed capacity, providing adequate staffing at all times, increasing administrator on-site hours or designating a qualified substitute, submitting personnel reports and supervision outlines, ensuring medications are available and administered on time, and conducting safety checks to secure chemicals and equipment.

Please continue on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 09/25/2025

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LIC 809-C

Licensee was provided a copy of Hospice Guide, Medication Guide, and Self-Assessment Guide. Additionally, CCL will submit a referral for technical support program.

Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC809 (FAS) - (06/04)

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