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Inspection visit

Follow-up

LEGACY SENIOR CARE IILicense 3459200843 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

On July 10, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Caregiver and explained the purpose of the visit. Today's visit, LPA requested R1's admission agreement as LPA has requested for the document on three separate occasion via email and/or phone call. LPA was informed by staff that R1's file was missing. LPA was unable to retrieve a copy. LPA is requesting for Administrator to submit admission agreement if there is an electronic copy stored. LPA and Caregiver discussed that all records are to be centrally stored inaccessible to others and inactive records are to be kept for three years. LPA was informed R1 passed away two weeks ago. LPA did not receive LIC 624A Death Report for R1. Additionally, LPA was informed that Administrator visits the facility approximately every three weeks. Administrator was not present during today's visit. LPA reviewed resident charting notes and took one photo of the notes for June 22, 2025. Deficiencies cited. Exit interview and a copy of report and appeal rights was provided.

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.

  • 87211(a)(1)(A)Type B

    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.

  • 87405(a)Type B

    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(d)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the July 10, 2025 inspection of LEGACY SENIOR CARE II?

This was a other inspection of LEGACY SENIOR CARE II on July 10, 2025. 3 citations were issued: 3 Type B.

Were any citations issued to LEGACY SENIOR CARE II on July 10, 2025?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: "87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may ..."

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.