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Inspection visit

Non-compliance follow-up

LEGACY SENIOR CARELicense 3459200633 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

On 10/14/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit. LPA met with staff, Mereisis Naisausau and explained the purpose of the visit. LPA notified Administrator, Adi Lina Tuiloma of LPA's presence at the facility. Administrator later arrived at the facility. During today's visit, LPA and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Storage space was inspected to confirm medications, toxins and sharps are locked and secured. LPA conducted a medication audit of three (3) residents. Resident #1 (R1) was prescribed Fluoxetine (40mg), Cyclobenzaprine (5mg) and Oxycodone (5mg) which were not present in the facility. Administrator said they will reach out to R1s doctor. Resident #2 (R2) was prescribed Clobetasol 0.05% ointment, Mupirocin 2% ointment and Terbinafine 250mg tablet which were not present in the facility. Administrator said they will reach out to R2s doctor. Resident #3 (R3) was prescribed Doxycycline 100 mg tablet and Levetriacetam 100 mg/ml solution which were not present in the facility. Administrator said they will reach out to R3s doctor. LPA conducted a file review of residents. All resident files contained required documents. Three (3) out of five (5) residents are non- ambulatory and require full or partial assistances with ADLs. One (1) resident is on hospice. One (1) resident requires a hoyer lift. Administrator stated that facility staff do not use the hoyer lift for R4. It is used for when transportation comes to take the resident to appointments. As a result of today's visit, deficiencies observed. Please see LIC 809-D. Copy of report and appeal rights provided during exit interview.

Citations

3 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.

  • 87405(d)(2)Type A

    87405Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:Based on medication audit and interviews facility did not comply to the section cited above as Administrator did not ensure medications are given as prescribed, which poses a immediate health and safety risk for residents 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 records reviewed, 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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  • 87465(a)(4)Type A

    87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 14, 2025 inspection of LEGACY SENIOR CARE?

This was a other inspection of LEGACY SENIOR CARE on October 14, 2025. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to LEGACY SENIOR CARE on October 14, 2025?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "87405Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections..."

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.