Legacy Senior Care II.

In addition, resident has not observed individuals selling drugs to other residents. LPA toured the facility and did not observe drug paraphernalia, and no one seemed under the influence of drugs or alcohol. Due to the information gathered, the department finds allegation unfounded. The department investigated allegation, “Staff are allowing residents to consume illegal drugs.” The department interviewed residents and staff and toured the facility. During interviews with residents, it was reported they have not observed resident’s taking drugs or possessing drug paraphernalia. LPA toured the facility and did not observe drug paraphernalia, and no one seemed under the influence of drugs or alcohol. Due to the information gathered, the department finds allegation unfounded. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report provided. 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 LPA spoke to a fire department representative and reviewed incident calls at the facility address. Representative stated there were no calls of service in April 2026. However, in March 2026, there was one call that occurred at 3:30 AM in which R1 fell and called 911 themselves. It was documented that when the fire department personnel arrived, R1 was accompanied by a caregiver and a housemate. Due to the information gathered, LPA finds allegation unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with caregiver Adilina Tuiloma during today's visit. Upon arrival there was 1 caregiver available until 10 am when a 2nd caregiver arrived. During today's inspection LPA toured the facility and observed resident rooms, common areas, kitchen, outdoor area, and staff area. LPA reviewed 6 of 6 resident files. LPA reviewed 6 of 6 resident medications comparing with physician orders and current MARS. During today's visit, no deficiencies cited. Exit interview conducted.

Licensing Program Analyst (LPA)s Hiratsuka and Mikkelson, conducted this announced annual visit. LPAs toured with Caregiver Manoa Namusudroka. Administrator Adilina Tuiloma arrived during visit. This facility currently has five residents. There are two shared and two private resident rooms. There is one full shared bathroom and one full bathroom in one of the shared resident rooms. A couple of resident rooms have exits to the outside. There is a locked laundry room and a staff room that is located by the kitchen. The dining, common, and kitchen areas were clean during this visit. There are two sheds in the backyard that are used for storage. There is a locked closet for medications and files. There are locked cabinets for cleaning toxins and sharps. Five of five resident records were reviewed. Six staff files were reviewed. Discussed with Administrator is logging of staff training. The staff do have training but some have logs that have dates, times, topics, and the length of time and some just have the training topics with the sheets signed. Staff do have training, but the logs are required to have the dates, times, topics, and length of time. The front gate was discussed. The gate is able to be opened but it can be difficult. Administrator stated she contacted a maintenance person and landlord about the gate to get it fixed or replaced. LPAs discussed leaving it partially open during the day time hours and close it at night without locking the gate. Resident supervision and audio alerts were discussed. Several other topics were discussed. No deficiencies cited.

The facility allowed excluded individuals to work in the facility. Documents reviewed indicated that all staff present at the facility and currently listed on the staff roster are fingerprint cleared and associated to the facility. Interviews conducted with Administrator indicated that there are no uncleared staff at the facility and Administrator explained how she conducts hiring and fingerprinting staff prior to start date at the facility. Therefore, the allegation the facility allowed excluded individuals to work in the facility is unfounded. Staff are forging resident documents. Documents reviewed indicated that all physician signatures were from separate physicians and matched other signatures in each resident specific files. All resident files included all documents to meet regulatory requirements. In review of the staff files, signatures and printed names matched each staff file. Therefore, the allegation staff are forging resident documents is unfounded. The Administrator is not present at the facility for a sufficient amount of time. Observations made on unannounced visits by the Department made on 01/08/2026 and 11/04/2025 which indicated that the facility’s administrator was present at the facility. Documents reviewed indicated that a current staff schedule is being followed and is accurate to current staff working. Therefore, the allegation the administrator is not present at the facility for a sufficient amount of time is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

Insufficient staffing Records reviewed indicated that staff have adequate training. Review of staff schedule indicated that there are staff scheduled to work to meet the residents in care needs. Interviews with Administrator, staff and residents indicated that staff are able to complete their daily tasks and assist all residents in care with their needs. Therefore, the allegation insufficient staffing is unsubstantiated. Facility is not arranging transportation to doctors appointments Interviews conducted indicated that administrator was assisting in scheduling transportation for doctors appointments. There were a handful of times that the third party transport company cancelled last minute causing the resident to miss their scheduled appointment. Administrator or facility staff are able to assist with taking residents to their appointments. Therefore, the allegation facility is not arranging transportation to doctors appointments is unsubstantiated. Medication mismanagement Records reviewed indicated that sodium tablets were prescribed but then discontinued in November 2025 by Resident R1’s primary care physician (PCP). Facility was using an updated medication list signed by R1's physician as reference to the medications given. Facility accurately discontinued the medications as requested by PCP. Interviews conducted indicated that resident R1 was willing and able to take their medications and does not have any refusals of medications. Therefore, the allegation medication mismanagement is unsubstantiated. Facility not providing a safe environment Records reviewed indicated that R1 and R3 were in a verbal altercation on 11/16/2025. No injuries were noted per incident report. Interviews indicated that staff are providing a safe environment for residents in care. Observations indicated that residents are safe and being taken care of by staff at the facility. Therefore, the allegation of facility not providing a safe environment is unsubstantiated. ** continued on 9099-C2 page** 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 Resident has wandered away from the facility Records indicated that there have not been any elopements from the facility. Resident R4 is considered an unsafe wandering risk but has not left the facility unattended while is care. Interviews conducted indicated that there have not been any elopements from the facility. Therefore, the allegation resident has wandered away from the facility is unsubstantiated. Resident's personal items were not safeguarded Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. Therefore, the allegation resident's personal items were not safeguarded is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. 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 Facility does not have sufficient food Observations made indicated that facility has the required two day perishable and seven day non-perishable food supply on hand. Meals are provided and portion sizes are adequate. Interviews conducted indicated that meals are served three times a day and residents can request secondary portions of meals if they would like. Therefore, the allegation facility does not have sufficient food is unfounded. Resident's personal items were not safeguarded Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. R1’s family contacted administrator and requested the missing items and they were found and belongings were given back to R1 and their family. Therefore, the allegation resident’s personal items were not safeguarded is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

On November 4, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit. LPA met with Administrator and explained the purpose of the visit. During LPA's previous visit conducted on Thursday October 30, 2025, LPA removed R1's file from the facility to produce copies. Facility was informed file shall be returned within three business days. Today's visit, LPA returned R1’s complete file that was removed from the facility on Thursday, October 30, 2025. No deficiencies cited. Exit interview conducted.

On October 30, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding an incident that occurred on October 9, 2025. LPA met with staff and explained the purpose of the visit. Today's visit, LPA was informed Administrator is unavailable due to an emergency. Today's visit, LPA obtained resident 's (R1) whole file. In accordance to: 87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: (3) Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed. LPA may return R1's file within three business days by Tuesday November 4, 2025. This matter is still under review by the Department. Exit interview conducted.

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. 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 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.

On September 16, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a Plan of Correction visit regarding the deficiency cited on August 28, 2025. LPA met with staff and explained the purpose of the visit. On August 28, 2025, it was observed that the facility’s fire door was left open for residents to pass by freely. The purpose of the fire door is to comply with 2022 CALIFORNIA FIRE CODE: 435.8.3.2 Group R-3.1 occupancies housing non-ambulatory clients: In a Group R-3.1 occupancy, bedrooms used by non-ambulatory clients shall have access to at least one of the required exits, which shall conform to one of the following: 1. Egress through a hallway or area into a bedroom in the immediate area which has an exit directly to the exterior and the corridor/hallway is constructed consistent with the dwelling unit interior walls . The hallway shall be separated from common areas by a solid wood door not less than 13/8 inch (35 mm) in thickness, maintained self-closing OR shall be automatic closing by actuation of a smoke detector installed in accordance with Section 716.5.9. 2. Egress through a hallway which has an exit directly to the exterior. The hallway shall be separated from the rest of the house by a wall constructed consistent with the dwelling unit interior walls and opening protected by a solid wood door not less than 13/8 inch (35 mm) in thickness, maintained self-closing or shall be automatic closing by actuation of a smoke detector installed in accordance with Section 716.5.9. 3. Direct exit from the bedroom to the exterior shall be of a size as to permit the installation of a door not less than 3 feet (914 mm) in width and not less than 6 feet 8 inches (2032 mm) in height. When installed, doors shall be capable of opening at least 90 degrees and shall be so mounted that the clear width of the exit way is not less than 32 inches (813 mm). 4. Egress through an adjoining bedroom which exits to the exterior. Please continue on LIC 809-C. 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 LIC 809-C The plan of correction of Licensee is to submit a plan to LPA if facility wishes to install a magnetic door opener; if not, then Licensee needs to submit a plan of how facility will ensure fire door remains closed – was due on September 2, 2025. Additionally, LPA contacted Licensee on September 8, 2025 as a reminder that POC was due. As of the date of visit, LPA has not received plan of correction. Failure to correct civil penalty has been assessed of $100 per day. Civil penalty will continue to accrue $100 per day until plan of correction is received. Exit interview, a copy of report and appeal rights was provided.

On August 28, 2025, Licensing Program Analyst (LPA) Cassie Yang conducted unannounced case management visit. LPA met with caregiver who stated Administrator is not at the facility at this time. When asked, LPA was informed Administrator has not been at the facility since last week. This visit is to deliver in-person of ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY. Facility understands this is an Immediate Exclusion and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.

On May 20 , 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding two deficiencies that was cited on April 25, 2025. LPA met with caregiver who attempted to contact Administrator who was unavailable. Today's visit, LPA explained that POCs has not been received yet, copies of the report with deficiencies were emailed to Administrator's email on file on April 25, 2025 at 5:26 p.m. POC were due May 9, 2025. LPA informed caregiver that Licensee is to submit the POCs as soon as possible as civil penalties will continue to accrue. 87458 Medical Assessment - POC: Licensee is to conduct an audit of residents medical assessment to confirm tuberculosis testing are conducted. Licensee is to schedule residents an appointment for tuberculosis testing if missing on file. 87211 Reporting Requirements - POC: Licensee is to review the Reporting Requirement regulation and submit a statement of complian ce to LPA. POC may be submitted via fax and/or email to Sacramento North Regional Office at: Fax: 916-263-4808 Email: sacramentonorthregionalofficeascp@dss.ca.gov As a result of today's visit, civil penalties were assessed for $100 per day it has not been received. Exit interview and a copy of report and appeal rights provided.

Licensing Program Analyst (LPA) Cheyenne Ratajczak conducted an unannounced case management visit on 11/21/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with caregiver Walesi Vakararawa and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 11/21/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms .

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.

, 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.. 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 . 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.