Legacy Lane Senior Living

Report specified resident events within seven days

87211 Reporting Requirements (a) Each licensee shall furnish… (1) A written report ... to the licensing agency and to the person responsible …(D) Any incident which threatens the welfare, safety or health of any resident … this requirements was not met as evidenced by staff not reporting suspected abuse that was reported to them by resident 1(R1) on the week of 9/19/25. Additionally, staff did not complete the required SOC 341 form and failed to complete a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency. This poses an immediate health and safety risk to residents in care.

Obtain required California clearance or exemption

"87355 Criminal Record Clearance(e) All individuals subject to a criminal record ... (2) Obtain a California clearance or a criminal record exemption as required by the Department or..." This requirement was not met as evidenced by: Based on interviews the facility staff did not comply with the section cited above due to unassociated and excluded persons having been present in this facility. This poses an immediate health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

"87405 Administrator - Qualifications and Duties d) The administrator shall ... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations." This requirement was not met as evidenced by: Based on interviews, record review, observations, Administrator did not ensure all adults entering gthe facility shall have a criminal record clearance or exemption. P1 and P2 are not associated to the facility nor is there any personnel records for them at the facility.

Diet quality and preparation in safe healthful manner

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirements was not met as evidenced by interview and observations made ofstaff not ensuring that resident's dietary needs are met. Additionally, It was observed that in between-meal nourishment or snacks were not made available for all residents in care. This poses an immediate health and safety risk to residents in care.

Maintain required personnel records for staff

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain ...This requirement was not met as evidenced by facilities not a record available for all working staff , this poses an immediate health, safety and personal rights risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties (a) all facilities shall have a qualified and currently certified administrator ...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified ... When the administrator is not in the facility ... a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities...This requirement was not met as evidenced by facilities not having a qualified administrator, this poses an immediate health, safety and personal rights risk to residents in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space and Access(a) Except as specified in subsection (b) ... disinfectants, cleaning solutions, poisonous substances ... and other similar items ...are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. this requirement was not met as evidenced by LPA observations of kitchen exhaust fan not working properly which poses a potential health, safety and personal rights risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.

Resident access to hazardous items with safety review

87309 Storage Space and Access: except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses a potential ealth, safety and personal rights risk to residents in care.

Maintenance and operation requirements for facilities

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) ... Based on record review and interview, this requirement was not met as evidenced by kitchen faucet water is 98 degrees F. This poses a potential health and safety risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.

Require physician order and label for PRN medication

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...and the label shall contain...information. This requirment was not met as evidenced by: Over the counter medication that are not prescribed by resident's doctor was administered to resident on 6/29/25 which poses an immediate health, safety and personal rights risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by LPA observations of administrator not being in the facilty for over a month with no known return date, this poses a potential health, safety and personal rights risk to residents in care.

Ensure hazardous items are locked and not unattended

Storage Space and Access: except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Provide resident hot water for personal care

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) Based on record review and interview, this requirement was not met as evidenced resident bathroom faucet measuing 144 degrees F and kitchen faucet water is measured at 98 degrees F. This poses a potential health and safety risk to residents in care.

Report specified resident events within seven days

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.

Admission agreement signing and dating deadline

87507 Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative ...no later than seven days following admission... This requirment was not met as evidenced by incomplete resent records which poses an immediate health, safety and personal rights risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.

Facility personnel sufficiency and competence

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.

Night supervision when dementia residents require it

Care of Persons with Dementia: For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement is in addition to requirements specified in Section 87415, Night Supervision. This requirement was not met as evidenced by Statements obtained from the licensee that there are no awake staff scheduled daily during overnight hours and confirmed by staff schedules and statements obtained from staff members present which poses an immediate health safety and personal rights risks to residents in care.

Ensure hazardous items are locked and not unattended

Storage Space and Access: except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of bleach, cleaning supplies and one sharp knife unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Store centrally held medications in locked secure place

Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by, LPAs observations of insulin medication being stored in a fridge in the garage that was not made inacessible to residents in care wich poses an immediate health, safety or personal rights risk to residents in care.

Facility must clear fire safety for bedridden persons

Based on observation, interview and record review, the licensee did not comply with the section cited above in. It was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. which poses an immediate health, safety or personal rights risk to persons in care.