Golden Legacy Elderly Care II.

LPA also received a voicemail from a resident following a facility inspection where LPA could hear the stereo volume in the background that exceeds appropriate levels in a shared living environment. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.

Additionally, LPA conducted interviews with Three staff members and three residents, all individuals interviewed denied ever witnessing the identified excluded individuals present at the facility. LPA showed pictures of identified excluded individuals and all persons interviewed did not recognize them. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. 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 The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of other is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.

On 5/8/26 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Legacy Elderly Care II RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Peni Vuidreketi and together conducted a tour of the home. LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed the ramp in the back of the facility from the back bedroom in in need of repair. The wood flooring is rotten and LPAs foot went through the flooring waking up the ramp. LPA also observed the sling door screen is broken and in need of repair/replacement. LPA measured the water temperature, temperature measured at 112 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

On 2/13/26 at 11:30am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management -deficiencies inspection to address deficiencies observed while conducting a complaint investigation. LPA met with staff Mereisi Naisausau. LPA Gould inspected the food supply and observed approximately 20 canned goods that had expired in 2024 or 2025. LPA observed staff dispose of expired food items. LPA reviewed 5 resident files and observed one resident file with no signed admission agreement, ID and emergency information or pre-placement appraisal for R1 (see LIC-811 dated 2/13/26). Additionally, LPA inspected the medication supply and observed staff member disposing of used syringes in common medication containers that do not meet the safety requirements outlined in title 22 regulations. Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights were provided to the facility.

On 6/24/25 Licensing Program Analyst (LPA) Holly Williams conducted a case management inspection to ensure that the facility has stayed in substantial compliance since the informal meeting on 5/15/25 and to ensure that the compliance plan has been completed. LPA called the Licensee Diane Garcia and together discussed the report and Garcia gave permission for S2 to sign the report. According to Diana Garcia the facility designated administrator (FDA) Stacy Smith is on leave from 6/16/25 to 6/30/25. LPA conducted an inspection and upon entering the facility LPA observed a new caregiver S1. In an interview, R1 stated that they have met the administrator one time. LPA asked R2 if they had seen the administrator Stacy Smith and R2 stated they did not know that person. LPA found that S1's criminal record clearance was not cleared for this facility. LPA asked for S1's file and the health screening and the personnel record was not filled out except for S1's start date which was 5/28/25. LPA observed employee time sheets for S1 and the time sheets start on 6/10/25. LPA checked the LIC500 and it has not been updated to the new employee that in the facility. According to the licensee's compliance plan, they were supposed to hire additional staff by 6/15/25. According to S1 and S3 and the time sheets there has only been one caregiver at a time working at the facility. According to the compliance plan, the Licensee Diana Garcia was supposed to have training completed for the staff on chemical storage and safety, medication administration, storage, documentation, and special diets by 6/10/25. LPA has not received any proof of the a fore mentioned training's. [Continued on 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 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights and the report were left at the facility at this time. Exit Interview

Licensing Program Analysts (LPAs) Holly Williams and LPA Charlie Yang arrived unannounced to conduct an annual inspection. LPA Williams called and spoke with facility licensee on the phone Diana Garcia and explained the purpose of the visit. LPA Williams asked Diana Garcia to come to the facility or to have the new administrator Stacy Smith be present. Garcia stated that Smith could not come because Smith is at the other facility and if Smith did not show up then Aisake Jemesa the caregiver can sign the report. 2 hours into the inspection the licensee Diana Garcia arrived at the facility. LPA Williams reviewed 6 resident files (R1-R6) and six staff files (S1-S6). LPA Williams toured the facility with Aisake Jemesa and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 82 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109.8 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams observed bathroom did not have a bath mat. LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed a locked cabinet for the storage of medication. LPA Williams observed unlocked cabinets for the storage of cleaning solutions. The garage was unlocked and the cleaning supplies and poisons were accessible to residents. LPA Williams observed the knives locked and inaccessible to residents. LPA Williams observed in R1's room a bag of candy, the smell of urine was strong, and medication was out and accessible. [Continue on 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 LPA Williams reviewed R1's LIC 602 and it stated that R1 is on a special diet and R1 cannot store R1's own medication. LPA observed LIC500 dated 3/20/25 states 1 staff member scheduled Tuesday through Saturday. LPA Williams observed a LIC500 that had the administrator working Saturday, Sunday, and Monday. LPA Williams while conducting record review found S1 did not have a health screening or a TB Test. LPA Williams interviewed 1 staff member (S7) and 1 resident (R1). The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility licensee at this time. Exit Interview

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver finding on a complaint and discovered unrelated deficiencies. LPA Williams texted Diana Garcia to inform her of deficiencies found and Garcia stated Josevata Turaga could sign the reports. LPA Moleski toured a resident's (R1's) room and observed a folding pocketknife with the blade extended alongside antacid tablets and numerous packages of nicotine gum on a small table next to the resident's bed. This facility is hereby cited per 22 CCR Sections 87465(h)(2) and 87309(a). This facility was previously cited on 11/6/24 for having medications unlocked, including the same kind of antacid tablets. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed. An exit interview was held with Turaga. Appeal rights and a copy of this report were left with Turaga.

In an interview, on 10/01/24, CM and HHN1 said they arrived at the facility on 9/6/24 to see R5 decompensating. In an interview, HHN1 said R5 was wheezing but R5’s lungs were clear. In an interview, HHN1 said it was anxiety. In an interview, HHN1 and CM said they asked S1 if S1 was administering R5’s inhaler and S1 said it was on the bed. In an interview, CM said they did not find an inhaler on the bed. In an interview CM and HHN1 said they looked for R5’s sensor on R5’s arm and it wasn’t there. In an interview, CM said S1 pulled out 2 bins with medication for R5 and HHN1 pulled out the inhaler and S1 said they had not seen that inhaler before. In an interview, both HHN1 and CM said that S1 had the Medication Administration Record (MAR) filled out to date but did not know what the medication looked like. In an interview, HHN1 said they asked if S1 is the one who gives all the medications to R5 and S1 said yes. In an interview, HHN1 said they asked where R5's diabetic monitor is and S1 said they did not know. In an interview, CM said on 9/25/24, S1 pulled out 2 bins with medication for R5 and the HHN1 pulled out the inhaler and S1 said S1 had not seen that inhaler before. In an interview, CM said that not all required medications were in the bin. LPA Williams asked who gives the injections of insulin and HHN2 said the staff members do. In an interview, HHN2 said that HHN2 educated S1 on how to give the injection and to apply the diabetic monitors. In an interview, HHN1 said that nursing only goes there once a week. In an interview, HHN2 said that R5 could inject themselves when R5 is feeling good but there are times when R5 cannot inject themselves. In an interview, on 9/6/24 CM said they took a picture of the food served to R5 and it was fried potatoes, hot-dogs with barbecue sauce and sent it to LPA Williams. In an interview with the administrator Garcia, Garcia told LPA Williams that Garcia has pictures of the meals that S1 is feeding to R5, When LPA Williams received pictures from Garcia, they were pictures of the diabetic meals that were sent to R5 by CM after they saw what R5 was eating. LPA Williams and Licensing Program Manager (LPM) Czarrina Camilon-Lee visited Golden Legacy II on 11/06/24 and went into R3’s room LPA Williams and LPM Camilon-Lee observed candy in a bag on the night stand and a bucket halfway filled with candy on the floor. When LPA Williams questioned S1 about the candy S1 said,” oh yeah R3’s family brought that.” LPA Williams reviewed R3’’s medical assessment (LIC602) that states R3 is pre diabetic and tests his blood sugar. LPA Williams reviewed the pre appraisal for R3 states that R3 should be on a diabetic diet and that R3 is taking Metformin which is a diabetic medication. In an interview, R5’s RP said that R5 would tell them that the food is not healthy, and the food was cold. In an interview, R5’s RP said R5 was served dinner while they were there, and RP had a chance to see the food the facility was serving. In an interview, R5’s RP said the food R5 was being served [Continued on 9099-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 was all starch and they would call it, “Junk Food.” According to the medical assessment (LIC602) R2 is supposed to have a soft diet and while LPA Williams and LPM Czarrina Camilon Lee were there R2 was served a sandwich with chips and grapes. In an interview, R5 stated that there was not planned activities. In an interview, R2, R5, and the CM all stated there are no planned activities. S4 said that there are not planned activities. Through record review, LPA Williams found that S1 only had 36.5 hours of training done when starting work at the facility when 40 is required. As a result of this investigation, LPA Williams finds the allegation(s) to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. The following deficiencies were cited per CCR Title section 87465(a)(4), 87628(b)(4), 87219(a)(4), 87468.1(a)(2), 87465(a)(2), 87411(c), and 87628(a) . An exit interview was conducted with Josevata Turanga. A copy of this report was provided to Josevata Turanga.

Licensing Program Analyst (LPA) Holly Williams and Licensing Program Manager Czarrina Camilon-Lee arrived unannounced for this complaint investigation. LPA Williams and LPM Camilon-Lee met with caregiver Misivono Qadroka and explained the purpose of the visit. The administrator Diane Garcia was asked to come to the facility but declined and asked if Garcia could call. During an interview with R3 LPA Williams found unlocked medications In resident night stand drawer accessible to anyone: Robitussin cough medicine and acid rescue. The following deficiencies cited. See LIC809-D. Appeal rights provided. This investigation consisted of record review and interviews with staff and residents. LPA Williams interviewed (R1-R4) and did record review for R3, R4, R2.

Licensing Program Analyst (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation and observed unrelated deficiencies. LPAs Moleski and Williams spoke with facility administrator Diana Garcia on the telephone and explained the purpose of the visit. Garcia said staff member Misivono Qadroka could sign this report in her absence. Upon arrival, LPAs Moleski and Williams observed a caregiver present in the facility (S1). LPA Williams reviewed Guardian records and observed S1 was not associated to this facility. S1 told LPA Moleski that they had been working at this facility since 9/1/24, and works five days per week. LPAs Moleski and Williams reviewed S1's file and observed that it was not complete. S1's personnel record (LIC 501) was not completed, did not include S1's educational history or past work experience, and was not signed by S1. This facility is hereby cited per 22 CCR Sections 87355(e)(2) and 87412(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with Qadroka.

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams spoke with licensee Diana Garcia over the phone and explained the purpose of the visit. During a prior visit, LPAs Moleski and Williams observed two backyard sheds, which have not been permitted for habitation and which have not been cleared by the fire department. During the visit, one of the sheds had an air conditioning unit running, but the windows were blocked. LPAs Moleski and Williams observed through the windows of the second shed personal affects, including food and medications, along with a pet cat. LPAs Moleski and Williams knocked on both sheds but received no answer. In an interview, Garcia said she and her mother had used and were still using the sheds for habitation on occasion. During this visit, LPAs Moleski and Williams observed a sewer outflow pipe which had spewed out toilet paper and feces at some previous time. The toilet paper and feces were dried up and caked onto the cement patio. A staff member (S1) said that the toilet paper and feces had been there for at least two weeks. This facility is being cited per 22 CCR Sections 87303(a) and 87204(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with staff member Mareta Teku.

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection. LPA met with direct care staff and explained purpose of visit. Administrator's Certification 1/3/2025. LPA and direct care staff toured the interior and exterior of the facility including common areas, resident bedrooms, resident bathrooms, staff room, kitchen, dining room, laundry area, and garage. LPA observed the facility to be clean and in good repair and to have sufficient furniture and lighting throughout. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed locked sharps locked cabinet designated for medications. Chemicals (2 bottles of bleach and 1 gallon of bug spray) are not locked up in back area of property. LPA observed grab bars and non-skid flooring in all bathrooms. LPA observed locked toxins in the laundry room and a supply of linens/towels/blankets on hand. Fire extinguishers was last inspected 2/28/2024. The facility conducts fire/disaster drills with residents on 2/9/2024. Smoke/monoxide alarms are working order. LPA observed a complete First Aid kit on site and measured the hot water at 113.2 *F in the bathroom. LPA observed all doors to have alarms. LPA observed seating on patio, a locked shed, and two gates that were unlocked and accessible. There were tree branches and debris in back of property. Workshop was locked with a cat looking out. Facility sketch shows workshop, but licensee stated mom stays there occasionally. Two old refrigerators, two washers, and two dryers which need to be removed. LPA reviewed five resident files and three staff files, including criminal record clearances. A review of staff records indicates not all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents for community care licensing to be submitted via email by April 16, 2024: Updated Facility Sketch, New Fire Clearance, LIC 308 Designation of Administrator, LIC 500 - Personnel Report, LIC 610E Emergency Disaster Plan, Copy of Administrator's Certificate, and Copy of Liability Insurance. ruth.wallace@dss.ca.gov Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are being cited. See 809-D's for citations. Immediate civil penalty of $500.00 was issued to facility. Failure to correct the deficiencies by the noted due date may result in an additional penalty being assessed. Exit interview conducted with direct care staff. Copy of reports and (LIC 811 Confidential Names) left at facility.