Correction check·August 12, 2025

On 8/12/25 Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced POC visit to the facility to verify correction of citations issued on 7/23/2025. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. The current census was 12. LPA Tamayo called Administrator at 9:23AM and left a voice message requesting a call back. LPA Tamayo revived a text message from Administrator stating " Sorry, I can't talk right now". LPA has not received any follow up from Administrator since 7/23/25. LPA observed 3 residents eating breakfast at the dining table between 9:00AM- 10:00 AM. At 11:40 AM, LPA observed S3 and S4 starting to prepare lunch. S2 stated they do not know the return date for Administrator. S2 stated they last spoke to Administrator via phone three days ago to consult regarding the facility. LPA observations and Staff statements confirm there has not been any administrator oversight for several months. LPA Tamayo last saw Administrator on 4/25/25 and has not seen them at the facility since 6/13/25. Per LIC 500 dated 7/2025 staff/administrator, Moira Ganavou (S5) , is scheduled to work Friday- Sunday 7:00 AM-7:00AM. S5 Administrator certificate expires 6/6/2026, however LIC 308 designates S2 as Responsible for the facility. S2 sated they are in the process of obtaining an Administrator Certificate, they provided verification of 80 hours of training, completed between 5/1/25-5/18/2025. S2 provided LPA with a written statement from administrator stating S2 has completed Administrator training and will be assigned as administrator once they obtain their pending certificate (6078436740). Continued on 809-C LPA did not observe S2 on the list of “Active Administrator Certificate Holders” during this visit. A Civil Penalty for failure correct for POC regarding administrator oversight. S2 states groceries are ordered and delivered via the Walmart Mobile applications. Groceries are delivered twice a week. S2 stated Administrator also places orders on their end if anything is ever needed for the facility. LPA observed enough food for 12 residents in care in the refrigerator. S2 stated two incident report (SIRs) were faxed into CCL RO on 8/8/25 and 8/9/25. LPA Tamayo did not observe any Incident reports that came in from the facility in the last month. S2 provided successful fax confirmation verification. LPA will add the SIRs to the facility file. S1 agreed to send in future SIR’s the Regional Office email to ensure timely reporting. LPA reviewed staff file for Donnovan Jr Williams, (S6). S6 is background cleared but is not associated to the correct facility (facility Legacy Senior Living, 342701230). S2 notified the Administrator and they remotely associated S6 to the facility via Guardian during this visit. LPA measured the hot water temperature in the kitchen faucet, hot water temperature was 105.3 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. POC for hot water temperature cleared. S2 provided LPA with POC verification was received confirming Staff completed training on storing of toxins, cleaning supply was completed on 7/25/25. POC for storage of toxins has been cleared. S2 stated Dementia Training for all staff was completed on 8/8/25. Upon record review, LPA observed an LIC 621 was updated for each resident. LPA requested the following documents to be submitted by 5:00PM on 8/13/2025: LIC 500 for May-August 2025 Continued on 809-C Licensee complied with the terms of the POC by POC due date for two out of three deficiencies cited under Title 22 Regulations on 7/23/25 and have been cleared. Original POC for administrator oversight dated 6/30/25, a CP was issued on 7/23/25 for Failure to Correct. Another Civil Penalty (CP) for failure to correct is applied due to outstanding plan of correction regarding administrator oversight. As a result of this POC visit one (1) deficiency was cited (See LIC809D). An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, Civil Penalty, POC clearance letters, and Appeals rights were provided to the facility.