Legacy Senior Care Ii

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidenced by: Based on interviews conducted, Licensee failed to notify R1's primary care physician of R1's change of condition as R1 was not eating as much and sleeping more, which poses an immediate risk for residents in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement is not met as evidenced by: Based on file review and interviews conducted, Licensee failed to comply as R1 was ordered special diet of pureed textured, nectar thick consistency, fortified diet on May 19, 2025, but facility did not give R1's the followin special diet as R1 did not like it which poses an immediate risk for residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Based on file review and interview, Licensee failed to comply as death report was not submited to Licensing until 11 days after occurrence, which poses a potential risk for residents in care.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement is not met as evidenced by: Based on file review, interview and observation, LPA observed S1 to be living at the facility without a criminal record transfer to the facility, which poses an immediate risk for residents in care.

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified...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. Based on observation and interview, Licensee did not comply as the appointed Administrator failed to comply with criminal record clearance regulations twice within a week which poses a potential risk to residents in care.

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulationsThis requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as S1 has been residing at the facility since October 27, 2025 without a criminal record which poses an immediate risk for residents in care.

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 is not met as evidenced by: Based on observation, Licensee did not comply as it was observed that there was feces on the doors and walls, which poses a risk for residents in care.

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, Licensee failed to comply as facility front gate was in disrepair where it was unable to open for residents to exit which poses an immediate danger for residents in care,

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, Licensee did not comply as LPA observed fire door to be hooked opened which poses a potential risk for residents in care.

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 in this section... This requirement is not as evidenced by: Based on observation, Licensee did not comply to the section cited above as LPA contacted facility via phone call and email on July 7, July 8 and July 9 for R1's admission agreement to be submitted to the Department but did not receive a response, which poses a potential risk for residents in care.

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...This requirement is not met as evidenced by: Based on file review, Licensee failed to comply as LPA arrived to retrieve a copy of R1's admission agreement but file was unable to be relocated, which poses a potential risk for residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by: Based on file review, Licensee failed to comply as LPA did not received a death report for R1 who passed away over two weeks ago, which poses a risk for residents in care.

Based on file review, the licensee did not comply with the section cited above as two out of five residents did not have tuberculosis testing documented on LIC602 which poses a potential risk for residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on file review, Licensee did not comply as LPA was made aware that R1 and R2 are at the hospital but no incident reports observed which poses a potential risk for residents in care.