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Inspection visit

Follow-up on corrections

LEGACY SENIOR CARELicense 3459200635 citations on this visit
5 citations recorded

Inspector’s narrative

What the inspector wrote

On 02/19/2025 Licensing Program Analyst (LPA) Cheyenne Ratajcak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced. LPA and LPM met with Administrator Adi Lina Tuiloma and explained the purpose of the visit. LPA and LPM conducted a case management visit to issue citations in relation to complaint control#: 59-AS-20241120120334 During the complaint investigation, it was found that S1 was not criminally record cleared or associated to this facility at the time the incident occurred. The Administrator admitted that the facility failed to request a criminal clearance association for S1. Additionally, the Licensee failed to report the incident related to the complaint investigation. During today's case management visit, LPA and LPM toured the facility, conducted interviews and records review. The following deficiencies were found: 1) S2 is a live in staff at this facility. S2 has worked 24 hours a day for the past 14 days without any additional staff assistance. There are currently six (6) resident's residing in the facility. Two (2) are receiving Hospice services and bedridden, one (1) of six (6) residents is diagnosed with Dementia and four (4) of six (6) resident's are non-ambulatory. Based on resident's needs and documentation, the department has determined that this facility does not have sufficient staffing. Based on Title 22, Section 87411(a), the facility shall ensure there are two (2) care staff on duty during all waking hours. 2) During a facility walk through, LPA and LPM found chemicals and toxins in the laundry room unlocked and accessible to resident's in care. Continued on 809-C 3) A review of resident records found the following R1) Admission agreement is not signed by resident and/or responsible party R2) Physician's Report/ LIC602 is not signed by physician 4) The department learned that the facility thermostat was inoperable for several days during November 2024 resulting in the facility not having heat. The licensee failed to report this incident to the department as required. As a result of todays visit deficiencies cited and civil penalties assessed. Exit interview conducted and a copy of the report and appeal rights was left at the facility.

Citations

6 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(2)Type B

    87211 Reporting Requirements(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) when the facility heater was out for two (2) days.

  • 87309(a)Type A

    87309 Storage Space and Access(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above due facility laundry room door being unlocked and open making chemicals assessable to residents in care.

  • 87355(e)(2)Type A

    87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above due to caregiver not being associated with the facility which poses an immediate health and safety risk to persons in care.

  • 87411(a)Type B

    87411(a) 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 is not met as evidenced by:Based on interviews and records, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.

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  • 87506(a)Type B

    87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above due two (2) out of six (6) residents files being incomplete with signatures.

  • 87468.2(a)(4)Type A

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on interviews the licensee did not comply with the section cited above as staff had left the facility and residents were left unattended.

FAQ · About this visit

Common questions about this visit

What happened during the February 19, 2025 inspection of LEGACY SENIOR CARE?

This was a other inspection of LEGACY SENIOR CARE on February 19, 2025. 5 citations were issued: 2 Type A (serious) and 3 Type B.

Were any citations issued to LEGACY SENIOR CARE on February 19, 2025?

Yes, 5 citations were issued (2 Type A, 3 Type B). The first citation was for: "87211 Reporting Requirements(2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents whic..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.