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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920084
Report Date: 02/12/2026
Date Signed: 02/12/2026 12:25:31 PM

Document Has Been Signed on 02/12/2026 12:25 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) 999-0140
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 4DATE:
02/12/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Tuitubou, UlaiasiTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On February 12, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a follow-up case management visit regarding LPA's visit conducted on January 8, 2026. LPA met with staff and explained the purpose of the visit. Staff contacted Administrator who informed LPA that she was unavailable to meet in person as she is occupied for an assessment at a different facility.

During LPA's visit conducted on January 8, 2026, the visit was regarding a death report LPA received which was reported late to Community Care Licensing. Interview was conducted with Administrator on January 8, 2026, which revealed that R1 was observed to be declining for a "couple" of weeks. Observations was reported to R1's responsible party but not to R1's primary care physician.

Additionally, file review was conducted which revealed that R1 is on a special diet of pureed textured nectar thick, but this special diet was not followed as R1 did not like the texture. Interview conducted with Administrator and staff conducted on January 8, 2026 revealed that day of R1's death, R1 was provided eggs and scrambled eggs for breakfast.

It was discussed over the phone with Administrator when a resident has a change of condition it is to be documented and reported immediately to primary care physician. Additionally, it was discussed over the phone with Administrator that if a special diet was ordered by a physician, facility is to follow and/or report to physician if there is any concerns where the special diet cannot be met.

As a result of today's visit, deficiencies were cited. Please see LIC 809-D.

Exit interview conducted and a copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
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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Document Has Been Signed on 02/12/2026 12:25 PM - It Cannot Be Edited


Created By: Cassie Yang On 02/11/2026 at 08:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY SENIOR CARE II
FACILITY NUMBER: 345920084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2026
Section Cited
CCR
87466

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
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Licensee is to create Administrator and caregiver's responsibility of resident observations and identify what steps are to be taken.

POC can be submitted to LPA:
email:cassie.yang@dss.ca.gov or
cclascpsacramentonorthro@dss.ca.gov and/or fax to 916-263-4808
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Based on interviews conducted, Licensee failed to notify R1's primary care physician of R1's change of condition as R1 was not eating as much and sleeping more, which poses an immediate risk for residents in care.
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The plan of correction is due within 24 hours on February 13, 2026. Failure to correct by due date may result to an additional civil penalty of $100 per day until received.
Type A
02/13/2026
Section Cited
CCR87555(b)(7)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement is not met as evidenced by:
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Licensee is to conduct an audit of resident records and establish the residents' special diets ordered by physician. POC should include resident names, special diets, and menu examples.

POC can be submitted to LPA:
email:cassie.yang@dss.ca.gov or
cclascpsacramentonorthro@dss.ca.gov and/or fax to 916-263-4808
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Based on file review and interviews conducted, Licensee failed to comply as R1 was ordered special diet of pureed textured, nectar thick consistency, fortified diet on May 19, 2025, but facility did not give R1's the followin special diet as R1 did not like it which poses an immediate risk for residents in care.
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The plan of correction is due within 24 hours on February 13, 2026. Failure to correct by due date may result to an additional civil penalty of $100 per day until received.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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