Legacy Adult Care

Type of visit: Required - 1 Year

On 9/15/2026 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced annual visit. LPA met with Care Givers, Kelly Gordon and Elizabeth Flores, explained reason for visit and was permitted entry into the facility. License/Administrator was contacted and arrived a short time later. A tour of the facility was completed inside and out. A health and safety check was completed on residents in care. There were 5 of 5 residents present during todays visit. Residents observed in common areas, in the yard and in their rooms. The facility is a 3 bedroom, 1 bath. Bedroom 2 and 3 are shared bedrooms. Care Tool was not accessible or used during this visit. Pathways and doors were clear and free from obstruction inside the facility. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last purchased 07/02/23 and observed to be fully charge. Fire extinguisher was last serviced by fire department 05/11/26. Last fire drill on conducted on 06/02/2026. 3 of 3 resident rooms observed to have the required furnishings and with adequate lighting. Chemicals and medications were located in locked cabinets/closets. LPA observed sufficient seating under covered patio areas. A sample of resident and staff files reviewed. Required documentation observed in 3 staff files (CPR/1st aid, personal record, health screening/TB, criminal record statement, fingerprint clearances and training)and 2 resident files (admission agreements, needs and services plans, medical assessments and TB, consent forms, id/emergency information, safeguarding valuables and personal rights) present and reviewed. CONT... CONT... The following issues were observed during today’s visit: At 9:29 am LPA observed a blue razor knife in the living room sitting on a table near the fireplace. Knife was observed unlocked and accessible to residents in care. Review of 2 of 2 resident files reviewed disclosed a potential risk to residents in care. Resident files reviewed and interview with licensee, disclosed 3 of 5 residents have a restricted health condition without an exception. Facility does not have a complete emergency and disaster plan. The plan is has inaccurate transportation information, information locations are marked TBD and not showing the location, utility shut off locations are blank, temporary shelter location does not have a location listed outside the immediate area. Deficiencies cited per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct and potential risk to the health, safety and/or personal rights of residents in care. LPA requested the following documents to be submitted to CCL by 09/18/2026: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) and a current copy of liability insurance in order to update the facility file. Exit interview was conducted with Licensee, Kristina. A plan of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to Licensee.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 17, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that at 9:29 am, LPA observed a blue razor knife in the living room sitting on a table near the fireplace. Knife was observed unlocked and accessible to residents in care. Review of 2 of 2 resident files reviewed disclosed a potential risk to residents in care. This poses an immediate health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee stated they will provide a plan of correction in writting. Staff training will be completed and an in-serivce sign in sheet will be provided to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87616(a) · Plan of correction due date: Sep 29, 2026

87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidence by: records reviewed and interviews conducted. The Licensee did not comply with the section cited above in that 3 of 5 residents have a restricted health condition without an approved exception. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: A training will be completed by the LVN for all staff and requests for exceptions will be provided to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(a) · Plan of correction due date: Sep 29, 2026

1569.695 Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:... This requirement was not met as evidence by: records reviewed. The licensee did not comply with the section cited above in that the facility does not have a complete emergency and disaster plan. The plan is has inaccurate transportation information, information locations are marked TBD and not showing the location, utility shut off locations are blank, temporary shelter location does not have a location listed outside the immediate area. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee stated the plan will be updated with corrected information and will be sent to CCL by POC date as proof of correction.

Type of visit: Required - 1 Year

On 8/7/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Staff (S1) Kelly Gordon. Administrator Hripsime Makaryan was present at facility upon LPA’s arrival. 4 clients were present during inspection. LPA toured facility with staff. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature measured at 33 degrees F. Freezer temperature was measured at 0 degrees F. Cleaning chemicals was observed stored and locked closet next to entry door. Fire extinguisher was observed with a service date of: 6/2/25. Fire drill last completed on 6/2/25. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Inside bathroom toured and observed to be operational. LPA observed grab bars next to toilet and in shower. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seating and shaded area under patio. During medication and MARS review, LPAs observed Centrally Stored Medication and Destruction Record (CSMDR) was complete. Medications were checked and observed kept locked in closet in the kitchen. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Samples of Staff files were reviewed and observed to have all the required documents. No deficiencies issued during this inspection. LPA is requesting the following documents be submitted to the Fresno CCL office by 8/21/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Licensee. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Required - 1 Year

On 8/12/24 Licensing Program Analysts (LPA) K. Kaur and J. Leffall arrived unannounced to conduct an Annual Inspection. LPAs introduced themselves, stated the purpose of the visit, and were allowed entry by staff Kelly Gordon. Staff contacted Administrator Hripsime Makaryan who arrived a short while later. 4 clients were present during inspection. LPAs toured facility with staff. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. During living room tour, LPA’s observed fireplace without a screen. Cleaning chemicals was observed stored and locked closet next to entry door. Fire extinguisher was observed with a service date of: 6/7/24. Fire drill last completed on 5/23/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. Inside bathroom toured and observed to be operational. LPAs observed grab bars next to toilet and in shower. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seating and shaded area under patio. LPA’s observed a portable built bathroom next to patio in backyard at 12:18 PM. Toilet observed without grab bars. During medication and MARS review, LPAs observed Centrally Stored Medication and Destruction Record (CSMDR) was incomplete. Medications were checked and observed kept locked in closet in the kitchen. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Staff files were reviewed and observed to have all the required documents. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Deficiencies are as follows: Outside Portable built bathroom without obtaining building permit, fireplace without screen, Centrally Stored Medication and Destruction Record incomplete, and missing grab bars in portable bathroom. Continued to 809C LPA is requesting the following documents be submitted to the Fresno CCL office by 8/19/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 12, 2024

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.