Legacy Lane Senior Living

Type of visit: Case Management - Health Checks

On 09/02/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced case management visit and met with the facility’s designated Administrator, Isikeli Tuikenatabua. LPA Lee conducted a brief interview with the Administrator Tuikenatabua. The facility’s current census was 13 residents. The purpose of the visit was to conduct a quarterly follow-up and assess the facility’s compliance with the requirements established during the informal conference held on 01/13/2026. The following areas were required to remain in compliance while the facility was under increased monitoring and subject to quarterly visits: • Food Inventory Supplies: LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that both the refrigerator and pantry are kept locked at night. Both staff 1 (S1) and staff 2 (S2) admitted to locking the food at night due to a resident 1 (R1) wandering at night and grabbing food out of the areas. Per Administrator Tuikenatabua, who stated that he was not aware staff were locking the area but admitted to locking both the refrigerator and pantry during LPA Lee’s visit on 05/12/2026. S1 stated that the areas are kept locked from 7:00 PM to 7:00 AM. • Accountability/Oversight of Licensee and Administrator: Per the informal meeting held on 01/13/2026, the Administrator agreed to conduct monthly self-assessments and mock inspections to ensure ongoing compliance. However, Administrator Tuikenatabua was unable to provide documentation showing these assessments and inspections were being completed monthly other than showing LPA Lee blank assessment forms. CONTINUED LIC 809-C • Criminal Record Clearances: LPA Lee reviewed staff criminal record clearances and verified that all staff and other individuals requiring caregiver background checks were fingerprint cleared and associated with the facility. • Reporting Requirements: LPA Lee reviewed the Department’s Electronic Facility Files and identified the following number of incident reports submitted for each month in 2026: January—1; February—2; March—2; April—2; May—1; June—0; July—0; and August—0. It was learned that R1 was sent out to the hospital on 05/19/2026 and 06/15/2026 and no incident report was provided to the department. It was also learned that R1 has a change in condition. During today’s visit, LPA Lee reviewed the facility’s incident report binder and observed no incident report regarding R1. • Maintenance and Operation: LPA Lee didn’t smell any incontinence odor during today’s visit. The facility was clean and in good repair. At 8:18 a.m., LPA Lee observed a bottle of Clorox Multi-Surface Cleaner with Bleach on top of a dresser in resident bedroom #1. No staff or residents were present in the room. The door leading to the courtyard and the bedroom’s entry door were open to ventilate the room. At 11:02 a.m., LPA Lee observed bottles of fabric and pet odor eliminator and glass cleaner stored on a shelf in the unlocked garage, making the cleaning products accessible to residents in care. • Record Keeping: LPA Lee reviewed 13 resident files and found four incomplete. The LIC 603A Resident Appraisal, LIC 603 Preplacement Appraisal Information, and LIC 625 Appraisal/Needs and Services Plan for four residents were blank despite being signed by Administrator Tuikenatabua and the residents. • Medication Administration: At 8:23 a.m., LPA Lee observed residents’ medications pre-poured into small containers and left unlocked while a resident (R2) reported that they were guarding the medications. LPA advised care staff S1 that medications must remain in their original containers, locked, and inaccessible to residents. S1 moved the medications to the garage; however, the garage remained unlocked. Administrator Tuikenatabua stated that he pre-poured the medications because S1 and S2 were new staff and are scheduled for medication training today 09/02/2026 and both staff date of employment was 08/28/2026. At 8:25 a.m., LPA Lee observed multiple residents’ eye-drop medications stored in a refrigerator-door bin inside the unlocked garage refrigerator, making the medications accessible to residents in care. PAGE 2 CONTINUED LIC 809-C At 8:41 a.m., LPA Lee observed three medication bottles on top of a table used by staff in the garage. Throughout the inspection, staff were observed entering and exiting the garage, and the garage door remained unlocked, making the medications accessible to residents in care. LPA Lee reviewed medications and MARs for two residents and found one incomplete. R3’s Lisinopril 20 mg and Gabapentin 1,000 mg were not documented on the MAR but was in the residents medication bin. Administrator Tuikenatabua stated that the medications were found in R3’s room on 09/01/2026 and that R3 independently attends medical appointments, obtains medications without notifying staff, and leaves the facility for church and other activities. However, R3’s LIC 602 Physician’s Report dated 04/27/2026 states that R3 cannot leave the facility unassisted, requires supervision, is occasionally disoriented and non-ambulatory, and cannot store medications independently. The Administrator acknowledged that R3 leaves without supervision despite redirection and that incident reports regarding these occurrences were not submitted to the Department. • Name Tags: Per the informal meeting held on 01/13/2026, the Administrator agreed to implement the use of staff name tags. However, during today’s visit, none of the three staff members present were wearing name tags. Per Administrator Tuikenatabua, who stated that he is trying to get approval from Licensee Cleopatra Gardiner in regard to the name tag. A mock name tag was shown to LPA Lee by administrator. • Fire safety and capacity: during today’s visit the census is 13 which shows the facility is operating within the capacity of the license. • Change in condition/reappraisals: LPA Lee reviewed Resident 1’s (R1’s) records and R1 was admitted to the facility on 04/16/2025. According to R1’s LIC 602 Physician’s Report dated 04/16/2025 and the facility’s LIC 603 Pre-Placement Appraisal Information dated 04/20/2025, R1 had mild cognitive impairment, required a diabetic diet, and had bowel and bladder impairment with occasional incontinence. R1 was described as mildly forgetful and frequently confused or disoriented. R1 was ambulatory but unable to leave the facility unassisted. R1 required assistance with bathing but was able to groom, eat, and use the toilet independently, although R1 occasionally did not make it to the toilet in time. PAGE 3 CONTINUED LIC 809-C R1’s LIC 625 Appraisal/Needs and Service Plan dated 04/21/2025, states that R1 independently performed all activities of daily living (ADLs). It further states that staff would observe and monitor R1 daily, document any changes or progress in the communication log, and be responsible for implementing R1’s care plan. However, R1’s updated LIC 602 Physician’s Report, dated 03/09/2026, indicates that R1 had experienced a change in condition. The report states that R1 had dementia, was unable to care for themself, was unaware of their surroundings, and was consistently confused and disoriented. R1 reportedly became aggressive when staff attempted to assist R1 and engaged in behaviors that did not make sense due to the progression of R1’s dementia. The physician’s report also indicates that the care home was requesting hospice services. During a complaint visit conducted on 07/30/2026 under complaint control number 27-AS-20260722141948, LPA Lee learned that R1was admitted to Home Health on 06/09/2026. During the visit, hospice personnel arrived at the facility to evaluate R1; however, R1 was denied for hospice services. It was also learned that R1’s condition had changed and that R1 has been defecating on themselves on multiple occasions. According to a True Care Hospice fax cover sheet, R1’s condition had continued to decline. The document states that R1 was not eating, was unable to walk, and required assistance with all ADLs. It further states that both R1’s responsible party and the facility were requesting a hospice evaluation. Additionally, R1 had been transported to the hospital on multiple occasions, however, the facility did not submit incident reports to Community Care Licensing Division (CCLD) regarding R1’s hospital visits or reported changes in condition. Furthermore, the facility did not complete a reappraisal addressing R1’s change in condition, despite R1’s LIC 625 stating that facility staff were responsible for monitoring R1, documenting changes, and implementing the necessary changes to R1’s care plan. As a result of today’s quarterly visit, deficiencies were cited and can be found on the LIC 809D pages. A civil penalty of $3,500 was issued during today's visit on LIC 421IM. An exit interview was conducted with Administrator Tuikenatabua and copies of the LIC 809, LIC 809D, LIC 421IM and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 23, 2026

87468.1(a)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This was not met as evidenced by: Based on interviews with two residents and two care staff during today’s visit, it was learned that the staff are locking up the refrigerator and pantry at night due to R1 wondering and going through the refrigerator and pantry and taking other residents’ food and having unclean hand while touching the food. This poses an immediate health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The Administrator will ensure that pantry and refrigerator will not be locked at all times. Inservice training regarding residents’ personal rights in all facility will be conducted and a statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 09/23/2026 by the end of the day along with staff sign in sheet for the trainings and training materials.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Sep 23, 2026

87309(a) 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 is not met as evidenced by: Based on observation, the licensee/administrator did not comply with the section cited above. LPA Lee observed toxins unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator agrees to conduct Inservice training on storage space and access training for all staff and ensured that all chemicals are not accessible to residents at all times. Administrator will email LPA Lee training documents; staff sign in sheet by 09/23/2026 at the end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 23, 2026

87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on observations and interviews LPA Lee observed medication made accessible to residents in care. This poses an immediate health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator/licensee stated that they will conduct an Inservice training course on incidental medical and dental care to all staff to ensure that medications are locked at all times. Training documents and staff sign-in sheet will be emailed to LPA Lee by 09/23/20/2026 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Sep 23, 2026

7465(h)(5) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based observations and interviews with the administrator resident’s medication was pre-poured into small container for morning medication pass. This poses an immediate health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator/licensee stated that they will conduct an Inservice training course on incidental medical and dental care to all staff to ensure that medications are not being pre-pour for any medication pass. Training documents and staff sign-in sheet will be emailed to LPA Lee by 09/23/2026 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 23, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator agrees to conduct Basic Services training for all staff and to include elopement and provide LPA Lee training documents and a sign-in sheet. Administrator stated that they will also have R3 reevaluated by her PCC. POC due by 09/23/2026 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 23, 2026

87463(a) Reappraisals. (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101… This was not met as evidence by: Based on record review and interview with administrator, the licensee/administrator did not ensure that they conducted an updated reappraisal for R1 who had a change in condition. This poses potential, health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Per discussion, the Administrator agreed to update all their residents' care plan. Administrator agreed to create a plan in place to ensure all residents' care plans are updated at least every 12 months or as needed when there is a change in condition. Administrator will complete a reappraisal for R1 to show R1’s change in condition. POC due (09/20/2026 end of day 5:00 PM) to pang.lee@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Sep 23, 2026

87211(a)(1) 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 was not met as evidence by: Based on observation, interview, and record review, the licensee/administrator did not comply with the section cited above. The licensee/administrator did not ensure to submit incident reports in regard to resident change in condition, resident being sent out to the hospital and resident’s elopement, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: The administrator stated that he will conduct reporting requirement training to all staff and ensure that incident reports are either fax or email to CCLD. Training and staff sign in sheet will be to pang.lee@dss.ca.gov by 09/20/2026 end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(2) · Plan of correction due date: Sep 23, 2026

§1569.69(a)(2) Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete six hours of initial training. This training shall consist of two hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and four hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Based on observation, the licensee/administrator did not comply with the section cited above. Per administrator and S1 and S2 no medication training was conducted prior to the staff assisting residents with their medications. This poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator agrees to conduct Inservice training to include six hours of training, and which two of those six hours will include hands-on-shadowing training regarding medication administration. Administrator will email LPA Lee training documents; staff sign the sheet by 09/20/20/2026 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Sep 23, 2026

87506(a) 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 observation, file review, and interview with the administrator, the licensee/administrator did not ensure that residents files are complete and maintained.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator agrees to conduct Inservice training for resident records for all staff. Administrator will email documents used for training and staff sign in sheet by POC due by 09/23/2026 end of day 5:00 PM.

Allegation investigated: The facility allowed excluded individuals to work in the facility.

On 07/30/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to the facility. LPA Lee met with Administrator Isikeli Tuikenatabua and explained the purpose of the visit. The purpose of the visit was to deliver the finding related to the allegation above. At the time of the visit, the facility census was 13. It was alleged that the facility allowed excluded individuals to work at the facility. The investigation consisted of interviews with facility staff and the Administrator, facility residents, and other relevant individual, as well as observation. During an interview, Administrator Isikeli Tuikenatabua acknowledged that Excluded Individual 1 (E1) had been present at the facility approximately August or September 2025. The Administrator stated that, as a newly appointed Administrator, they were unaware that E1 and E2 were excluded individuals and admitted that E1 would come to the facility to provide assistance when Administrator contacted E1. CONTINUED LIC 9099-C Substantiated The Administrator further acknowledged that E2 was present at the facility in December 2025 during a Community Care Licensing Division (CCLD) visit. Two additional staff, S1 and S2 also acknowledged that E1 and E2 were in the facility in December of 2025 as well. Five of the nine residents interviewed reported seeing both E1 and E2 at the facility. Additionally, during a separate case management visit on 12/04/2025, Licensing Program Analyst (LPA) Avelina Martinez observed E2 present at the facility. Based on interviews conducted during the investigation. LPA Lee was able to corroborate the allegation that excluded individuals were present in the facility. This was observed not in compliance with Title 22 regulation 87777(a) Exclusions as the facility did not ensure an excluded individuals were not permitted to be present in the facility. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Administrator Tuikenatabua and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. An immediate civil penalty of $500 was assessed during today's visit. Per Administrator Tuikenatabua they take the residents LIC 602 Physician’s report with the residents to the resident’s primary care provider to have the report complete and filed out and that depending on the PCP it is either completed during the visit, or it can be faxed over to the facility. In interviews with nine out of nine residents in care, all who stated that either the facility, family members or themselves take them to the clinic for their appointments and that the facility calls EMS if needed. On 02/17/2026, LPA Lee conducted a visit to the facility and collected LIC 602 Physician’s Reports for eleven residents. Based on the records reviewed, all Physician’s Reports contained physician signatures and were filled out and complete. On 03/18/2026, LPA Lee contacted the Licensed Medical Professionals who had completed the residents’ LIC 602 Physician’s Reports; however, they were unable to provide information or verify whether the records were forged or falsified. Based on the information obtained, there is insufficient evidence to substantiate the allegation that the facility is forging resident documents. It was alleged that the Administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with facility staff, residents, a review of facility records, and observations. Based on interviews, three of three staff members denied the allegation. Staff S1 and S2 stated that the Administrator is Isikeli Tuikenatabua, who also goes by the nickname "Twoey" to make it easier for residents to pronounce the name. Both staff reported that the Administrator is at the facility "every day" and "all the time," generally from 7:00 a.m. to 7:00 p.m., and expressed no concerns regarding the allegation. The Administrator denied the allegation and stated that their work schedule is consistent with the facility's LIC 500, Personnel Report. Additionally, interviews with nine of nine residents identified "Twoey" as the person in charge of the facility and stated that they’re at the facility “everyday.” A review of the facility’s LIC 500 Personnel Report states that the Administrator is scheduled to work Monday through Friday from 7:00 a.m. to 7:00 p.m. The Department has conducted eight visits to the facility, and during those visits, the Administrator was present seven out of eight facility visits. Based on interviews, records reviewed, and the Department's observations, there is insufficient evidence to support the allegation that the Facility Administrator is not present at the facility for a sufficient amount of time. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 27-AS-20260211150501

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a) · Plan of correction due date: Jul 30, 2026

87777(a) Exclusions The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. This requirement was not met as evidenced by: The facility did not ensure excluded individuals (E1) and (E2) were prohibited from being at a licensed facility. (E1) and (E2) were observed at the facility on multiple occasions.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Effective immediately, all excluded individuals are prohibited from entering or being present at the licensed facility. The Administrator stated that they will ensure no excluded individual is permitted to work, provide services, visit, or otherwise be present at the facility or have any contact with residents or staff. The Administrator will submit a written plan to CCLD outlining the procedures that will be implemented to ensure excluded individuals are not allowed to work, provide services, interact with residents or staff, or enter the facility in the future. An immediate civil penalty in the amount of $500 was assessed during today's visit.

Allegation investigated: Staff did not notify residents authorized representative of an incident Staff left resident in soiled clothing Staff did not ensure resident wore protective helmet Staff are not communicating with resident's authorized representative regarding appointments Staff are not managing resident's pain Staff did not ensure the facility was kept clean Staff are not meeting resident's hygiene needs

On 06/09/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to initiate and conclude a complaint investigation. LPA Lee met with care givers Pene Henefiro and Merewalesi Qalikaisi. The facility census was eleven residents, with two staff members present at the time of the visit. A phone interview was conducted with facility administrator Isikeli Tuikenatabua. It was alleged that staff did not notify resident's authorized representative of an incident, staff left a resident in soiled clothing, staff did not ensure resident wore a protective helmet, staff are not communicating with the resident's authorized representative regarding appointments, staff are not managing resident's pain, staff did not ensure the facility was kept clean and staff are not meeting resident's hygiene needs. The investigation consisted of record reviews and interviews with Administrator Tuikenatabua and the Reporting Party (RP). Based on a review of the resident roster, it was learned that there are no residents by the name of Resident 1 (R1) residing at the facility. CONTINUED LIC 9099-C Unfounded During an interview with Administrator Tuikenatabua who confirmed that there is no resident by the name of R1 who resides at the facility. Additionally, the Reporting Party stated that R1 resides at 9442 Mazatlan Way, Elk Grove. Further review determined that the complaint was filed against the incorrect facility. R1 does not reside at Legacy Lane Senior Living located at 7610 La Mancha Way, Sacramento. Rather, R1 resides at Legacy Lane Senior Living III, located at 9442 Mazatlan Way, Elk Grove. Therefore, the allegations are not associated with the facility identified in this complaint investigation. The Department has investigated the complaint allegations listed above and determined the complaint to be UNFOUNDED, meaning the allegations were false, could not have happened, and/or was without reasonable basis. Therefore, the complaint has been dismissed. No deficiencies were observed or cited during today’s complaint visit. An exit interview was conducted with care staff Henefiro.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 27-AS-20260604100942

Type of visit: Case Management - Health Checks

On 05/12/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a case management visit for a health and safety inspection. The facility is currently on quarterly monitoring due to non-compliance concerns discussed during an informal Microsoft Teams meeting held on 01/03/2026. Upon arrival, LPA Lee met with designated Administrator Isikeli Tuikenatabua and explained the purpose of the visit. At the time of the visit, the facility census was nine (9) residents, with three (3) staff members present. LPA Lee and Administrator Tuikenatabua toured the physical plant to ensure the health and safety of residents in care. Areas inspected included, but were not limited to, the kitchen, resident bedrooms, resident bathrooms, living room, dining room, and outdoor areas. LPA Lee observed the facility to be free of odors, and activities such as board games, puzzles, and books were available for residents in the common area. LPA Lee also observed a public telephone located in the common area. The facility thermostat was observed at 73 degrees Fahrenheit, which is within the required regulatory range of 68 to 85 degrees Fahrenheit. During the inspection, LPA Lee observed toxins stored in a kitchen cabinet and in the garage. It was learned that toxins and sharp knives located in the garage were not secured in a locked cabinet or container. Administrator Tuikenatabua stated that the toxins and sharp knives did not need to be separately secured because residents do not have access to the garage and the garage itself remains locked. CONTINUED LIC 809-C However, during the visit, LPA Lee observed Administrator Tuikenatabua and two care staff entering and exiting the garage multiple times without securing the garage door, making the toxins and sharp knives accessible to residents in care. LPA Lee advised Administrator Tuikenatabua that if the facility chooses to continue storing toxins and sharp knives in the garage, the garage must remain locked at all times and be immediately resecured each time staff enter or exit the area. Alternatively, the facility may install a locked and secured cabinet within the garage to store toxins and sharp knives, ensuring the items remain inaccessible to residents even when staff are frequently entering and exiting the garage. LPA Lee inspected medication storage and observed medications to be locked and inaccessible to residents. Hot water temperature in a resident bathroom sink measured 116.1 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit. LPA Lee inspected the fire extinguisher and observed that it was last serviced on 03/26/2025. LPA Lee informed Administrator Tuikenatabua that fire extinguishers are required to be serviced annually. Based on records reviewed and information provided by Administrator Tuikenatabua, the last fire drill was conducted on 09/01/2025. LPA Lee informed the Administrator that fire drills are required to be conducted every three months. LPA Lee observed that the facility has two refrigerators, one located in the kitchen and one in the garage. Both refrigerators were observed to be dirty and unsanitary. LPA Lee informed Administrator Tuikenatabua and care staff that the refrigerators must be maintained in a clean and sanitary condition. During the visit, one care staff cleaned the kitchen refrigerator. LPA Lee followed up on the following areas: • Food Inventory Supplies: LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that the seven-day nonperishable food supply was being stored in the locked garage. Per Administrator Tuikenatabua, the food was locked due to a previous resident who wanders at night to eat. CONTINUED LIC 809-C • Accountability/Oversight of Licensee and Administrator: Per the informal meeting held on 01/03/2026, the Administrator agreed to conduct monthly self-assessments and mock inspections to ensure ongoing compliance. However, Administrator Tuikenatabua was unable to provide documentation showing these assessments and inspections were being completed monthly. • Criminal Record Clearances: LPA Lee reviewed staff criminal record clearances and verified that all staff and other individuals requiring caregiver background checks were fingerprint cleared and associated to the facility. • Reporting Requirements: LPA Lee reviewed the facility’s incident binder and compared it with the Regional Electronic Facility File. Based on records reviewed, there were two incidents in March 2026, with only one reported; three incidents in April 2026, with only one reported; and one incident in May 2026, as of 05/12/2026, which had not been reported. • Maintenance and Operation: LPA Lee observed one kitchen cabinet in disrepair. Administrator Tuikenatabua acknowledged awareness of the damaged cabinet and stated that repairs were needed. • Fire Safety: During today’s visit, the facility census was nine (9) residents in care. • Record Keeping: LPA Lee reviewed five (5) of five (5) resident files and observed them to be complete. LPA Lee also reviewed three staff files and found one file incomplete. At the time of record review Staff 1’s (S1) file did not contain documentation of employee orientation or the required 40 hours of training completed prior to working at the facility. S1’s employment date was 12/01/2025. Approximately two hours later, Licensee Cleopatra Gardiner texted Administrator Tuikenatabua a photograph of S1’s orientation and 40-hour training documentation. Administrator Tuikenatabua did not have in his file the 20 additional hours of continual training for the year 2025. CONTINUED LIC 809-C • Medication Administration: LPA Lee reviewed medications and medication administration records (MARs) for three residents and found discrepancies involving two residents. Resident 1 (R1) had two creams, Hydrocortisone 2.5% and Clotrimazole 1%, present at the facility; however, only Hydrocortisone 2.5% was listed on the MAR. Administrator Tuikenatabua stated that Clotrimazole 1% had been discontinued, but no documentation supporting the discontinuation was available. Additionally, LPA Lee observed that R1’s medications for 05/02/2026 remained inside the bubble pack despite being initialed on the MAR as administered. Further review of R1 and R2’s medications revealed that staff were administering medications out of sequence by removing medications from week two of the bubble pack before completion of week one, indicating the facility was not following the bubble pack instructions as prescribed. • Name Tags: Per the informal meeting held on 01/03/2026, the Administrator agreed to implement the use of staff name tags. However, during today’s visit, none of the three staff members present were wearing name tags. • Administrator Oversight: Per the informal meeting held on 01/03/2026, the Licensee stated they would ensure the Administrator complied with all applicable laws and regulations while employed at the facility. However, LPA Lee observed multiple deficiencies during today’s visit. As a result of today’s quarterly visit, deficiencies were cited and can be found on the LIC 809D pages. A civil penalty of $500 was issued during today's visit on LIC 421IM. An exit interview was conducted with Administrator Tuikenatabua and copies of the LIC 809, LIC 809D, LIC 421IM and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 30, 2026

87303(a) 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 was not met as evidence by: Based on observations two of the facility refrigerators were dirty and unsanitary. A kitchen cabinet was observed broken. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: The Administrator Tuikenatabua agrees to conduct weekly refrigerator check and clean to ensure that the refrigerators are clean at all times. Log starting today 05/12/2026 to the end of the month will be email to LPA Lee by 05/30/3036 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: May 22, 2026

1569.695(c) Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill… This requirement was not met as evidence by: Based on record review and an interview with Administrator Tuikenatabua, the facility did not ensure quarterly fire drills were conducted, which poses a potential health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator Tuikenatabua agreed to conduct and document fire drills every three (3) months on the facility’s fire drill log. Administrator will conduct a fire drill for the month of May 2026 and continue conducting drills every three (3) months thereafter. Proof of the completed May fire drill for 2026, along with a statement acknowledging review and understanding of the cited regulation, will be emailed to LPA Lee by 05/22/2026 by the end of the day.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: May 22, 2026

569.625(b)(2) Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours… (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training… This requirement was not met as evidence by: LPA Lee reviewed five (5) of five (5) resident files and observed them to be complete. LPA Lee also reviewed three staff files and found one file incomplete. At the time of record review Staff 1’s (S1) file did not contain documentation of employee orientation or the required 40 hours of training completed prior to working at the facility. S1’s employment date was 12/01/2025. Approximately two hours later, Licensee Cleopatra Gardiner texted Administrator Tuikenatabua a photograph of S1’s orientation and 40-hour training documentation. Administrator Tuikenatabua did not have in his file the 20 additional hours of continual training for the year 2025. This poses potential health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: The Administrator Tuikenatabua agrees to ensure that all staff have 20 additional hours of continual training each year. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: May 22, 2026

87211(a)(1) 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 requirement was not met as evidence by: LPA Lee reviewed the facility’s incident binder and compared it with the Regional Electronic Facility File. Based on records reviewed, there were two incidents in March 2026, with only one reported; three incidents in April 2026, with only one reported; and one incident in May 2026, as of 05/12/2026, which had not been reported, which poses a potential health and safety and/or personal rights risk to persons in care. This poses potential health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator agrees to send LPA Lee LIC 626/incident reports and to review the applicable 22 CCR sections regarding reporting requirements, and to send LPA Lee a signed statement acknowledging these requirements by POC due date 05/22/2026 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 13, 2026

7203 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: LPA Lee inspected the fire extinguisher and observed that it was last serviced on 03/26/2025, which poses an immediate health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator will get the fire extinguisher serviced no later than tomorrow 05/13/2026 and provide LPA Lee proof of service along with a statement acknowledging and understanding of the cited regulation emailed to LPA Lee by 05/13/2026 by the end of the day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(3) · Plan of correction due date: May 22, 2026

87468.1(a)(3) Personal Rights of Residents in All Facilities a. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This was not met as evidenced by: LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that the seven-day nonperishable food supply was being stored in the locked garage. Per Administrator Tuikenatabua, the food was locked due to a previous resident who wanders at night to eat. This poses an immediate health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: The Administrator will ensure that pantry will not be locked and a statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 22, 2026

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: LPA Lee reviewed medications and medication administration records (MARs) for three residents and found discrepancies involving two residents. Resident 1 (R1) had two creams, Hydrocortisone 2.5% and Clotrimazole 1%, present at the facility; however, only Hydrocortisone 2.5% was listed on the MAR. Administrator Tuikenatabua stated that Clotrimazole 1% had been discontinued, but no documentation supporting the discontinuation was available. This poses an immediate health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: he Administrator will ensure that physician orders are followed at all times and ensure that the residents of MAR log are current and accurate at all times. In addition, the administrator will ensure that all residents medication is being administered not out of sequence and following the correct week per the bubble pack instructions. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 22, 2026

87309(a) 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 is not met as evidenced by: Based on observation, the Administrator did not comply with the section cited above. LPA Lee observed toxins and sharp knives unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator agrees to put a locked cabinet in the garage to store the chemicals and sharp knives and have it locked at all times. Administrator will email LPA Lee photo of the cabinet with the chemicals and knives by 05/22/2026 end of day 5:00 PM.

Type of visit: Office

An informal meeting was conducted today on 1/13/26 at the Sacramento Regional Office via Microsoft Teams. The purpose of this informal meeting was to discuss the recent trends that have been observed by the Department has made while investigating them. Present at this meeting were Licensing Program Manager (LPM), Czarrina Camilon-Lee, Licensing Program Analysts (LPAs), Cynthia Tamayo and Avelina Martinez, Designated Facility Licensee, Cleopatra Gardiner and Administrator, Isikeli Tuikenatabua. LPM Camilon-Lee explained the Informal Conference process which included the Administrative Process as well. The facilities have been licensed since November 2024 of which the facility has been cited for 7 Type A citations, and 19 Type B citations. The focus of concerns at this time were as follows: 1. Personal Rights: Food 2. Accountability/Oversight of Licensee and Administrator 3. Uncleared persons assisting residents 4. Reporting Requirements 5. General food requirement: Food Inventory supplies and ensuring that resident's dietary needs are met. 6. Maintenance and operation 7. Fire safety: not operation beyond the capacity of the license Technical Support Program (TSP) assistance was offered and the licensee stated they are interested in TSP and a referral will be made on their behalf. CONTINUED ON 809-C The facility has stated they will do the following to achieve continued and substantial compliance: 1. Administrator has agreed to ensure only cleared persons may assist the facility operations and assist residents 2. Administrator agrees to conduct reappraisals as needed or at least annually. 3. Administrator agrees to continue to Inventory quality food is at the premises and available to residents in care, food supplies will be replenished as necessary. 4. Administrator agrees to conduct self-assessments and conduct mock inspections to ensure continued facility compliance at least once monthly. 5. Provide LIC 500 identifying Administrator and licensee hours for Legacy Lane. The LIC 500 must list all individuals should to attend the facility and shall be updated whenever there is a change in staff roster/schedule. 6. Administrator agrees to not operate outside of approved fire clearance capacity. 7. Administrator agrees to ensure timely Reporting Requirements are followed. 8. Administrator agrees to ensure accurate medication administration 9. Licensee ensures Administrator is adhering to all applicable laws and regulations at all times while employed. All proof of training and documentation for the items listed above will be sent to the LPA Cynthia Tamayo by 02/02/26 at cynthia.tamayo@dss.ca.gov. These actions are not punitive, but collaborative as ways to improve on areas of concern are addressed. According to the California Code of Regulations, Title 22, no citations were delivered during this meeting and a copy of this report was provided. A copy of this report will be emailed to licensee/administrator for signature and sent back with signature to the Department by 1/14/2026. The licensee should be advised at the end of the Informal Meeting that failure to correct deficiencies by the given due dates, agreed upon during the meeting, could result in a Non-Compliance Conference. Exit interview conducted.the state’s words, verbatim · CDSS document, Jan 13, 2026

Allegation investigated: Facility staff hit resident.

Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on December 19, 2025, at 12:15 PM and met with Administrator Isikeli Tuikenatabua. The purpose of the inspection is to deliver complaint findings for the above allegation. Based on complaint investigation interviews and records reviewed, it was determined that there was not sufficient evidence to prove that a facility staff member hit resident 1 (R1). Confidential interviews were conducted with eight individuals during the period of November 13, 2025, to December 04, 2025. continued... Unsubstantiated Three out of three staff members reported they did not hit R1. LPA Martinez interviewed five out of five residents. Three out of five residents reported that staff did not hit R1, and they have never witnessed staff members hitting residents. One out of five residents declined to be interviewed. Based on information obtained during the investigation, R1 reported that a staff member hit them, but did not provide the name of the staff. During an interview with R1, they denied being hit by a facility staff member. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 27-AS-20251110133553

Allegation investigated: Staff failed to report suspected sexual abuse of a resident Staff did not ensure that resident's dietary needs are met

On 12/4/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez arrived unannounced to conduct a complete and deliver complaint investigation findings into an allegations noted above. LPA met with administrator, Isikeli Tuikenatabua (S2), and stated the purpose of this visit. LPA requested the following records for review: • LIC 500 • LIC 9020 • LIC 308 Allegation: Staff failed to report suspected sexual abuse of a resident It was alleged that Staff failed to report suspected sexual abuse of a resident The investigation into the above allegation consisted of interviews and record reviews. CONTINUED ON 9099-C Substantiated During interviews with two staff (S2 and S5) and two residents (R1 and R2) it was learned that Resident 1 (R1), whom is a dependent adult, reported to S2, P1, S6 and P2, that they had been inappropriately touched by Staff 3 (S3) on 9/23/25. Record review and interviews confirm that S1- S7, P1, and P2 did not complete report the incident timely to community care licensing regional office via unusual/special report, phone call, nor an SOC 341 form. S1-S7 are mandated reporters, however they did not ensure timely reporting requirements were completed when the R1 reported they were inappropriately touched in a sexual manner to staff. Based on interviews and observations of the LPA and review of records the allegation that staff failed to report suspected sexual abuse of a resident, is substantiated. A civil penalty for repeat violation applies. Allegation: Staff did not ensure that residents’ dietary needs are met It was alleged that staff did not ensure that residents’ dietary needs are met, this investigation consisted of facility observation, interview with residents in care, and resident records review. On 9/29/2025, LPA Tamayo conducted a visit to the facility and observed 5 residents sitting at the dining room table having lunch and dinner in which they were consuming food items that did not meet their prescribed dietary requirements; it was observed that staff preparing lunch was frozen corn dogs and pizza.R6 has a diagnosis of diabetes and there is no special menu nor alternatives offered for them. Interview with 2 out 5 residents revealed concerns with food being served. 5 out of 5 residents in the facility stated in between meal snacks are not being provided. LPA did not observe snacks were made available to residents in between meals during multiple visits including 4/25/25,6/13/25,6/30/25,7/23/25,8/12/25, and 9/29/25. Additional review of facility’s Admissions Agreement indicates that residents in care will receive nutritious and well-balanced meals that meet their individual dietary meals requirements. This was observed not in compliance with Title 22 regulation 87555(a). LPAs did not observe any fresh fruit out on the counter available to residents. LPAs observed waffles, oranges, and grapes were given for breakfast and lunch was burgers, chocolate cake, orange, and soda. S2 stated canned soup is available for anyone who wants an alternative. Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that resident's dietary needs are met, is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Allegation: staff sexually abused a resident, the investigation It was alleged that staff sexually abused a resident, the investigation into the above allegation consisted of interviews and record reviews. On 09/29/2025 and 10/07/2025, Resident 1 (R1) was interviewed by the department, R1 reported that they had been inappropriately touched by Staff 3 (S3) on 09/22/2025, after S3instructed by R1 to apply Witch Hazel around her groin area and upper inner thighs. R1 denied penetration and that S3 touched their clitoris. R1 recalled S3 saying, “It’s good for me to massage you” and “Let me know when it feels good,” while applying the Witch Hazel. R1 reported other caregivers do not massage them while applying the Witch Hazel. R1 asked S3 to stop touching her and they did. Based on the interview, the information has no basis to support an allegation of sexual abuse. Four staff (S2,S4, and S5) were interviewed and two residents (R1-R2) of which none reported to have witnessed any staff sexually abuse a resident. Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff sexually abused a resident. Allegation: Staff did not ensure that facility is maintained clean It was alleged that staff did not ensure that facility is maintained clean, the investigation into the above allegation consisted of interviews and record reviews . Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure that facility is maintained clean It was, is unsubstantiated. Allegation: staff did not ensure that residents’ incontinence needs are met It was alleged that staff did not ensure that residents’ incontinence needs are met, the investigation into the above allegation consisted of interviews and record reviews. R1 reported there was two occurrences when incontinence care was not met. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming . Based on interviews and observations of the LPA and review of records, there is not a preponderance of the evidence to prove staff did not ensure that resident's incontinence needs are met. CONTINUED ON 9099A-C Allegation: Air conditioner is not in good working order, It was alleged that the air conditioner is not in good working order, the investigation into the above allegation consisted of interviews and record reviews. On 9/29/25, R1-R5 stated the air conditioner is in working order. S2 stated they contacted a maintenance worker the week of 9/15/25 when they noticed the Air conditioner was not operating properly and it was fixed immediately. Based on interviews and observations of the LPA and review of records the allegation the Air conditioner is not in good working order is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of the above allegations are unsubstantiated, but if any additional information is received this complaint can be amended and the findings can be changed. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 27-AS-20250919152014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 5, 2025

87211 Reporting Requirements (a) Each licensee shall furnish… (1) A written report ... to the licensing agency and to the person responsible …(D) Any incident which threatens the welfare, safety or health of any resident … this requirements was not met as evidenced by staff not reporting suspected abuse that was reported to them by resident 1(R1) on the week of 9/19/25. Additionally, staff did not complete the required SOC 341 form and failed to complete a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Administrator submitted LIC 624 to LPA Tamayo on 9/29/25. By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87211 Reporting Requirements in addition to a plan to train all staff on mandated reporter requirements. POC can be submitted to cynthia.tamayo@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Dec 12, 2025

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirements was not met as evidenced by interview and observations made of staff not ensuring that resident's dietary needs are met. Additionally, It was observed that in between-meal nourishment or snacks were not made available for all residents in care. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87555 General Food Service Requirements in addition to a plan to ensure that resident's dietary needs are met and all foods shall be selected, stored, prepared and served in a safe and healthful manner. ADministrator also stated new cooking staff will be hired. POC shall be submitted to Cynthia.tamayo@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 12/4/2025, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez conducted an unannounced Case Management -Deficiency visit to the facility. LPAs met with facility administrator Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Interview statements from two staff (S1 and S2), it was learned that unassociated individuals. On two separate accounts LPAs were informed two unassociated individuals were present at the facility. It was reported P1 and P2 were present at the facility the on or around 9/23/25 and 12/4/25. It was discovered that P1 is the former administrator/licensee at facilities 342700499 342700440 and 342700730, which were closed as of July 2025.Upon guardian and LIS roster review, it was observed that P1 and P2 are on probation and not associated to Legacy Lane Senior Living. A civil penalty applies for having individuals who are excluded and/or not associated to the facility. During site visit on 12/4/25 around 9:00 AM,LPA Martinez observed P2 and two other unassociated individuals were present outside of the facility. It was confirmed P2 was present in the facility on 12/4/25 and LPAs were informed by facility staff that P2 is at the facility approximately once per week to assist with maintenance work, and they are also called to order supplies and materials needs at the facility. S2 stated R1 called them on 9/23/25, stating “something happened”. S2 stated they were not working at the facility on the week of 9/20/25 due to working at another facility (Vita Bella Elderly Care) and that is why S2 called P1, in order to ask them to come to the Legacy Lane Senior Living in order to have a female speak with R1. S2 stated there was no other administrator or designated responsible person on site, only care staff, so they called P1, whom is their former employer to come to Legacy lane in order to assist with speaking to R1. CONTINUED ON 809-C LPA Martinez spoke with S1 over the phone at around 10:35 AM and S1 confirmed they are in New York and have been out of the facility since May 2025 and will return "soon". They will contact LPA Martinez back with a return date. Licensee stated they understood an informal office meeting will be scheduled. Moreover, LPAs provided guidance on the following: Reporting requests for missed medications and advised staff to maintain an accurate refusal log, and update resident Re-appraisal if the last one was done over 12 months ago or there was a change of condition, whichever occurs first. A civil penalty shall be assessed on December 04, 2025 , in the amount of $200.00 due to background clearance violations (Criminal Record Clearance 87355(e)(2)). Refer to LIC 421BG form for additional information. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2, and a copy of these LIC 809 reports, LIC 809-D page, LIC 421BG, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 5, 2025

"87355 Criminal Record Clearance (e) All individuals subject to a criminal record ... (2) Obtain a California clearance or a criminal record exemption as required by the Department or..." This requirement was not met as evidenced by: Based on interviews the facility staff did not comply with the section cited above due to unassociated and excluded persons having been present in this facility. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Licensee and admnisitrator stated P1 and P2 will not return to the facility without clearances. By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87355.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Dec 5, 2025

"87405 Administrator - Qualifications and Duties d) The administrator shall ... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations." This requirement was not met as evidenced by: Based on interviews, record review, observations, Administrator did not ensure all adults entering gthe facility shall have a criminal record clearance or exemption. P1 and P2 are not associated to the facility nor is there any personnel records for them at the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87405.

Type of visit: Required - 1 Year

On November 13, 2025, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Isikeli Tuikenatabua and explained the purpose of today's visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate expires on September, 02 2027. The facility is licensed for fourteen non-ambulatory clients. There are currently twelve residents who reside at this facility. The facility has an approved hospice waiver for one. There are currently no residents receiving hospice care. The LPA Martinez toured the facility with Isikeli Tuikenatabua on November 13, 2025, at 11:00 AM. LPA Martinez reviewed five resident files and five staff files. The resident and staff files were maintained. LPA Martinez reviewed two medication administration records (MAR), and both MARS and medication orders were maintained. LPA Martinez reviewed the Infection Control Plan and Emergency and Disaster Plan. The facility's last fire drill was on September 01, 2025. The fire extinguisher was last inspected on March 26, 2025. The facility wired fire alarms was last inspected on April 11, 2025. The smoke detectors and carbon detectors were tested, and they are in good repair. The facility has a public telephone and has an area for activities. The toxins and medications are made inaccessible. The facility has a first aid kit. The laundry area is maintained and sanitary. The resident bedrooms and bathrooms are furnished. The water temperature measured at 108 degrees and and facility temperature measured at 68 degrees. Continued... Common areas were furnished and sanitary. The facility kitchen is furnished and had an adequate food supply. There are no cameras installed at the facility. The exterior of the facility is clear of debris and has a covered patio with seating. As a result of this annual inspection visit, there were no deficiencies cited at this time. An exit interview was held, and a copy of this report was given to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: POC

On 9/29/2025, Licensing Program Analyst (LPA) Cynthia Tamayo and Licensing Program Manager (LPM) Czarrina Camilon-Lee conducted an unannounced Case Management POC visit to the facility to verify correction of citations issued on 8/12/LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Current administrator/Licensee (S1), Cleopatra Gardiner was not present at the facility. S2 called S1. Administrator, Cleopatra Gardiner, was contacted via phone call and informed she will return to the facility next Monday, 10/6/25. S1 stated that S2 will be instated as administrator, and agreed to send request for change of administrator on this day. LPA and LPM met with Direct care staff, Isikeli (S2) Tuikenatabua. The census is 13. LPM spoke with staff regarding ensuring all exits are and staff supervision requirements. Staff 3 (S3), LPA Tamayo, and LPM Camilon-Lee went on a tour of the facility. LPA and LPM observed the garage door was unlocked and there were cleaning supplies and toxins including laundry detergent and medications in the entrance area of the garage, accessible to residents. A deficiency and civil penalty for repeat violation was applied. LPA observed S2 lock garage door immediately. LPM observed staff preparing lunch was frozen corn dogs and pizza. LPA did not observe any snacks to be distributed. LPA/LPM observed the smoke detectors went off when staff where preparing lunch. LPA Tamayo observed the exhaust fan is not working. LPA observed staff preparing dinner around 4:30 PM which included frozen chicken strips, frozen French-fried that were prepared in the oven, and watermelon and melon mix. LPA observed a lock mechanism in a kitchen drawer, S2 stated they used to lock the refrigerator but do not practice doing so any longer. Continued on 809-C Staff 5 (S5) was present and working at the facility on 9/23/25. S5 does not have a staff record for review as required by Title 22 regulations. . LPA obtained for four residents (R1-R4) records and four staff records . Licensee failed to correct an outstanding plan of correction regarding administrator oversight. A civil penalty issued for failure to correct deficiency was last cited on 8/13/2025, in which the original deficiency was cited on 6/30/25. S2 emailed LPA their Administrator Certificate during this visit, however, the LIC 308 designates another staff as responsible representative and the complete POC has not been submitted to LPA Tamayo by the Licensee. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, LIC 421FCs, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 30, 2025

87309 Storage Space and Access(a) Except as specified in subsection (b) ... disinfectants, cleaning solutions, poisonous substances ... and other similar items ...are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Facility has agreed to lock disinfectants, cleaning solutions, poisonous substances, and medications etc. located in the garage and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 10, 2025

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 was not met as evidenced by LPA observations of kitchen exhaust fan not working properly which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Licensee will have exhaust fan repaired by POC due date. Licensee will send maintenece work order/invoice to LPA Tamayo at cynthia.tamayo@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Sep 30, 2025

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 ... When the administrator is not in the facility ... a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities... This requirement was not met as evidenced by facilities not having a qualified administrator, this poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Facility must designate a qualified administrator to facility at all times. Licensee will submit an updated LIC 308,provide a statement of review and understanding for 87405(a), and a plan to ensure there is always a qualified Administrator to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Oct 3, 2025

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain ... This requirement was not met as evidenced by facilities not a record available for all working staff , this poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2025

Plan of correction: Licensee will submit a statement of review and understanding for 87412(a) and a plan to ensure there is always a personnel record for all past and future staff and volunteers effective by POC due date. Licensee will also ensure all on-call/ back up staff are listed on all future LIC 500 Personnel Record forms

Type of visit: POC

On 8/12/25 Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced POC visit to the facility to verify correction of citations issued on 7/23/2025. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. The current census was 12. LPA Tamayo called Administrator at 9:23AM and left a voice message requesting a call back. LPA Tamayo revived a text message from Administrator stating " Sorry, I can't talk right now". LPA has not received any follow up from Administrator since 7/23/25. LPA observed 3 residents eating breakfast at the dining table between 9:00AM- 10:00 AM. At 11:40 AM, LPA observed S3 and S4 starting to prepare lunch. S2 stated they do not know the return date for Administrator. S2 stated they last spoke to Administrator via phone three days ago to consult regarding the facility. LPA observations and Staff statements confirm there has not been any administrator oversight for several months. LPA Tamayo last saw Administrator on 4/25/25 and has not seen them at the facility since 6/13/25. Per LIC 500 dated 7/2025 staff/administrator, Moira Ganavou (S5) , is scheduled to work Friday- Sunday 7:00 AM-7:00AM. S5 Administrator certificate expires 6/6/2026, however LIC 308 designates S2 as Responsible for the facility. S2 sated they are in the process of obtaining an Administrator Certificate, they provided verification of 80 hours of training, completed between 5/1/25-5/18/2025. S2 provided LPA with a written statement from administrator stating S2 has completed Administrator training and will be assigned as administrator once they obtain their pending certificate (6078436740). Continued on 809-C LPA did not observe S2 on the list of “Active Administrator Certificate Holders” during this visit. A Civil Penalty for failure correct for POC regarding administrator oversight. S2 states groceries are ordered and delivered via the Walmart Mobile applications. Groceries are delivered twice a week. S2 stated Administrator also places orders on their end if anything is ever needed for the facility. LPA observed enough food for 12 residents in care in the refrigerator. S2 stated two incident report (SIRs) were faxed into CCL RO on 8/8/25 and 8/9/25. LPA Tamayo did not observe any Incident reports that came in from the facility in the last month. S2 provided successful fax confirmation verification. LPA will add the SIRs to the facility file. S1 agreed to send in future SIR’s the Regional Office email to ensure timely reporting. LPA reviewed staff file for Donnovan Jr Williams, (S6). S6 is background cleared but is not associated to the correct facility (facility Legacy Senior Living, 342701230). S2 notified the Administrator and they remotely associated S6 to the facility via Guardian during this visit. LPA measured the hot water temperature in the kitchen faucet, hot water temperature was 105.3 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. POC for hot water temperature cleared. S2 provided LPA with POC verification was received confirming Staff completed training on storing of toxins, cleaning supply was completed on 7/25/25. POC for storage of toxins has been cleared. S2 stated Dementia Training for all staff was completed on 8/8/25. Upon record review, LPA observed an LIC 621 was updated for each resident. LPA requested the following documents to be submitted by 5:00PM on 8/13/2025: LIC 500 for May-August 2025 Continued on 809-C Licensee complied with the terms of the POC by POC due date for two out of three deficiencies cited under Title 22 Regulations on 7/23/25 and have been cleared. Original POC for administrator oversight dated 6/30/25, a CP was issued on 7/23/25 for Failure to Correct. Another Civil Penalty (CP) for failure to correct is applied due to outstanding plan of correction regarding administrator oversight. As a result of this POC visit one (1) deficiency was cited (See LIC809D). An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, Civil Penalty, POC clearance letters, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Aug 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 13, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Original POC dated 6/30/25 was not completed by POC due date. CP was issued on 7/23/25 for Failure to Correct. Another CP was issued 8/12/25 for failure to correct. Facility will designate a qualified administrator to facility at all times by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Cynthia Tamayo made an unannounced POC visit to the facility to verify correction of citations issued on 6/30/2025. An extension for POCs was requested and granted with a new POC due date of 7/18/2025. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Administrator, Cleopatra Gardiner, was contacted via phone call and informed she will return to the facility "early next week". Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. The current census is 12. An extention was granted for 6 out of 6 POC's dated 6/30/2025. POC verification for 4 out of 6 POCs dated 6/30/2025 has not been received by the Regional Office as of today, 7/23/25, the POC's are overdue. A civil penalty for failure to correct applied due to outstanding plan of correction regarding water temperature regulations, staff training, and administrator oversight. S2 stated they call Administrator when they have updates or questions but there has not been an administrator on site for a while. It is unclear how long the administrator has been off site due to inconsistent responses, but it may be two to three months since the Administrator has last been at the facility. On 7/1/25, LPA emailed S1 POC's dated 6/30/25 and requested a S1 contact LPA, but LPA has not received a response. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were kept locked and inaccessible to residents. [continued on 809-C] Staff submitted SIR for medication error and completed medication administration training on 7/18/25. POC clearance letter generated. Facility also submitted Death Report for Cal Susimmout was received. POC clearance letter generated. S2 stated a maintenance person came and replaced the water heaters. LPA measured the water temperature in the resident bathrooms and the temperature measured 115.7 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA measured the water temperature in kitchen faucet, temperature measured at 91.97 degrees F which does not meets the 105-120 degree Fahrenheit regulation. Per staff statement, staff training on Storage Space and Access has not been conducted and will be competed upon Administrator's return. S2 stated meal times are 8:00AM-9:00AM for breakfast, 12:00-1:00 PM for Lunch and 4:30PM-5:30PM for Dinner each day. The following documentation was requested to be submitted to the department: -LIC 500 (April-July 2025) A technical advisory/ violation was provided for sections 87218, 87415, 87705, and 87706. Per the California Code of Regulations, Title 22, The following deficiencies are cited during today's inspection. Immediate civil penalties will be issued due to failing to correct citations and failing to complete the plans of correction identified in the previous licensing report. Appeal rights and a copy of LIC 809 and LIC 809-C left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(b) · Plan of correction due date: Aug 11, 2025

87309 Storage Space and Access: 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 evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses a potential ealth, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: POC dated 6/30/25 was not completed by POC due date. Licensee conduct a training regarding 87309 Storage Space and Access for all staff members. Licensee will provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Aug 11, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: POC dated 6/30/25 was not completed by POC due date. Facility will designate a qualified administrator to facility at all times by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Aug 11, 2025

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) ... Based on record review and interview, this requirement was not met as evidenced by kitchen faucet water is 98 degrees F. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Licensee will schedle maintenace to regulate water temperature attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a case management (CM) Plan of Correction POC follow up visit. LPA Tamayo met with facility staff Isikeli Tuikenatabua (S2) and explained the purpose of the visit. Ombusdman Byron Toiliver was also present during this visit. Upon arrival, LPA Tamayo observed three staff members (S2-S4) present and working. Administrator, Cleopatra Gardiner (S1) was not present during this CM POC follow up visit nor was she at the facility during the last case management visit that was conducted on 6/13/25. on 6/13/25,S2 stated S1 was not working that day due to being out sick. On 6/17/25, LPA Tamayo emailed a copy of the 809-D from CM visit that took place 6/13/25. S1 responded back via email on 6/17/25 stating they will submit the POC by the due date of 6/27/25. No POC verification has not been received by the Regional Office as of today, 6/ 30/ 2025 and POC is overdue. A civil penalty for failure to correct applied due to outstanding plan of correction regarding reporting requirements. Additionally, a posted LIC 500 Personnel Report dated 6/202/25 indicates S1 is scheduled to work Monday thru Wednesday 7:00 AM-7:00 PM. There is no LIC 308 on file or submitted to Community Care Licensing informing the administrator will be out of the facility and who is designated facility responsibility. The return date for the administrator is unknown by staff (S2, S3, S4 ) and residents (R1, R2, R3. During today’s visit S3 stated has been out of the facility on vacation in New York for about one month. Three residents stated they have not seen S1 for a long time for about “2 months” and do not know where S1 is. Initially, S2 stated S1 has been out on vacation for two weeks, but when LPA Tamayo asked why staff (S3) and 3 residents (R8, R4,and R3) say they have not seen S1 for 1- 2 months. [continued on 809-C] S2 then stated that S1 has not been at the facility since 1 month and does not know S1’s return date. S2 stated they are “kind of” in charge while S1 is out. S2 called S1 via phone call and they sent over an LIC 308 which designates S2 as responsible. S2 stated they do not have an administrator certificate. LPA Tamayo is concerned for the operation of the facility due to having no/minimal administrator oversight. LPA measured the water temperature in the two resident bathrooms, temperature measured at 144 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA measured the water temperature in kitchen faucet, temperature measured at 98 degrees F which does not meets the 105-120 degree Fahrenheit regulation. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept unlocked and accessible to residents. LPA observed toxins including cleaning products such as Clorox and Lysol sprays were located in bathroom cabinet and under the kitchen and kept locked and inaccessible to residents. LPA observed S2 lock both cabinets immediately during this visit when asked to do so. As this is a repeat violation, an additional civil penalty of $250 is hereby assessed. LPA reviewed Resident Records for R1-R8 and observed there were incomplete forms including missing signatures/name, dates, and information for resident forms including consent forms to receive medical treatment and admission agreements. LPA reviewed Physicians report for residents (R1-R8). R3 is prescribed Morphene (To be administered three times per day). LPA saw there is no Morphene medication left, as the 90 pills were filled on 5/22/25 and were finished on 6/21/2025. However, MARS records show that S2 signed off on Morphene medication being administered to R3 three times a day 6/22/25-6/29/25 and at 8:00AM on 6/30/25. S2 stated they signed/initialed the MARS for R3 Morphene medication was taken but they shouldn’t have from 6/22-6/20/2025. Additionally, S2 stated they gave R3 their personal over the counter Tylenol on 6/29/25 around noon due to R3 having pain. Tylenol is not listed for R3. LPA Tamayo was concerned about R3’s medical state and asked R3 if they would like EMS to be contacted. R3 requested immediate medical attention at 3:40 and EMS was immediately contacted by S2. EMS arrived at 3:55PM and transported R3 to the hospital. LPA Tamayo reminded staff an Unusual Incident Report (UIR/SIR) is required for Emergency Transport of residents. S2 gave LPA Tamayo SIR at 4:30PM. Continued on 809-C No Plan of Correction for CM visit dated 6/13/25 has been received, a civil penalty is assessed due to failure to correct. The follong deficiencies are cited on the corresponding 809-D per California Code of Regulations, TITLE 22. At 6:54 PM and exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jul 7, 2025

Storage Space and Access: 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 evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Facility has agreed to: lock cabinets containing disinfectants, cleaning solutions, poisonous substances, etc. and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jul 7, 2025

87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by LPA observations of administrator not being in the facilty for over a month with no known return date, this poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Facility has agreed to: Communicate with LPA Tamayo to inform CCL of Administrator return date. Assign a qualified certified administrator during Administrator absence.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 7, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Licensee failed to correct Deficiency cited on 6/13/25 by POC due date on 6/27/25. Licensee agrees to send timley reports and provide verification of review and understanding of regualtion 87211 to LPA Cynthia Tamayo by POC due date at cynthia.tamayo@dss.ca.gov . A Civil Penality is assessed for failure to correct.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: Jul 7, 2025

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) Based on record review and interview, this requirement was not met as evidenced resident bathroom faucet measuing 144 degrees F and kitchen faucet water is measured at 98 degrees F. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Licensee will schedle maintenace to regulate water temperature attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jul 4, 2025

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...and the label shall contain...information. This requirment was not met as evidenced by: Over the counter medication that are not prescribed by resident's doctor was administered to resident on 6/29/25 which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Facility agrees to submit an SIR for medication administration error. Licensee will provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Jul 1, 2025

87465 Incidental Medical and Dental Care (c)... facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(3)A record of each dose is maintained in the resident's record... the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirment was not met as evidenced by: Staff signed off that resident received a prescribed medication from 6/22-6/31/5 even though they did not administer medications, as the medication were done by 6/21/25. which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Licensee will submit an SIR to Community care Licenseing for medication administration errors. Licensee will conduct training for all staff members and provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(c) · Plan of correction due date: Jul 7, 2025

87507 Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative ...no later than seven days following admission... This requirment was not met as evidenced by incomplete resent records which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Resident records for all residents will be filled out, signed, and dated by POC due date and submitted to LPA Tamayo via email.

Allegation investigated: ) Staff handled resident roughly. 2) Unlawful eviction.

Licensing Program Analysts (LPA) Cynthia Tamayo made an unannounced inspection to the Legacy Lane RCFE on 6/13/25 at 8:57 A.M. to conclude the investigation of the above allegations and to deliver the findings. LPA Tamayo met with staff, Isikeli Tuikenatabua and together discussed the purpose of the visit. This investigation consisted of interviews, observation, and record review. Six residents (R1-R6) and four staff members (S1-S4) were interviewed. LPA Tamayo reviewed six residents' (R1 and R6) files. According to Rebecca Danenberg’s (R1) admission agreement, dated 2/5/24 R1's LIC 602 diagnosed R1 with Paraplegia and Venous insufficient. Cognitive deficits were identified for R1 include hypertension, anxiety, and PTSD. Substance abuse problem identified on LIC 602 for R1. R1 was identified as non-ambulatory, which means that the resident should be able to turn, rotate, and/or reposition themselves in bed and assistance with dressing is needed. Report Continued on LIC 9099-C. Unsubstantiated LPA conducted an interview with RP who reported allegations made by R1. LPA interviewed R1 and they stated they requested to be moved and were not given an eviction notice. Methodist Hospital assisted R1 with obtaining a new placement. LPA reviewed resident record for R1. Five (5) current residents’ interviewed reported that they like the staff and are well cared for. No concerns regarding care were voiced by residents who were interviewed. Current residents interviewed did not voice specific concerns regarding the conduct of S2. S1, S2, S3 stated no staff has handled residents roughly. S1 stated R1 was hospitalized on 3/9/2025 and was relocated to another facility that can better assist her with the adequate care including their need for a special size mattress and Hoyer lift due to R1's weight. Residents and staff interviewed could not verify that this incident occurred as described by R1. The department has determined the following as it relates to the allegations that staff handled client roughly and unlawful eviction. Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding these allegations. Exit interview was conducted with facility staff. A copy of this report were left at the facility.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 27-AS-20250311084847

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Cynthia Tamayo made an unannounced inspection to the Legacy Lane RCFE on 6/13/25 at 8:58 AM to conduct a Case Management Deficiency visit. LPA Tamayo met with staff, Isikeli Tuikenatabua and explained the purpose of the visit. Tamayo conducted an in-person interview with Cleaopatra Gardiner (S1) on 3/13/25 at 9:00 A.M. S1 informed LPAs that resident, Cal Sisommout (R2) died. LPAs conducted a record review and found that no incident report was submitted to CCL. No Death Report on file. S1 stated that a Death Report was not submitted because R2 was transported to hospital via hospice and died at the hospital. S1 stated they did not know she had to report the death to Community Care Licensing. This facility is hereby cited per Title 22 . An exit interview was held with Tuikenatabua . Appeal rights and a copy of this report were left at the facility.the state’s words, verbatim · CDSS document, Jun 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jun 27, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: Licensee agrees to send timley reports and provide verification of review and understanding of regualtion 87211 to LPA Cynthia Tamayo by POC due date at cynthia.tamayo@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 4/25/25 at 12:40pm Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced case management inspection to address previous incident reports and deficiencies in facility operation. LPAs met with administrator, Cleopatra Gardiner and together discussed observations and incident reports. Upon entering the LPA Gould observed bleach and cleaning supplies unsecured from residents in care. LPA Gould also observed one large kitchen knife unsecured in a kitchen drawer with no lock. LPAs conducted file review and observed inconsistencies with pre-placement evaluations and resident's physician reports as the needs and services required for residents were not consistent with physician evaluations. Based on LPA observations and resident file review, LPAs have determined, based on resident needs, there must be awake night staff available at the facility to meet resident needs during overnight hours. Staff performing overnight duties must be awake and be present on the facility lower level during all overnight hours identified as between 10:00 pm to 6:00 am. Additionally, the department has determined the facility did not meet resident needs for care and supervision for residents present with documented behaviors such as wandering, elopement and aggressive behaviors as identified by residents physician reports. This was documented by an incident report dated 4/11/25 where a resident eloped from the facility and the resident's physician report indicated that resident is unable to leave the facility unassisted. Report Continued on LIC 9099-C. Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. An Immediate $500 civil penalty was issued during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Apr 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 2, 2025

Storage Space and Access: 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 evidenced by LPA observations of bleach, cleaning supplies and one sharp knife unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2025

Plan of correction: Facility has agreed to: Facility has agreed to conduct training for all staff members and will provide training materials to the department by The POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: May 2, 2025

Personnel Requirements - General: 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 was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2025

Plan of correction: facility has agreed to: Facility has agreed to provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: May 2, 2025

Care of Persons with Dementia: For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement is in addition to requirements specified in Section 87415, Night Supervision. This requirement was not met as evidenced by Statements obtained from the licensee that there are no awake staff scheduled daily during overnight hours and confirmed by staff schedules and statements obtained from staff members present which poses an immediate health safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2025

Plan of correction: facility has agreed to: Facility has agreed to provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision.

Type of visit: Case Management - Deficiencies

On 3/13/25 at 11:00am Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo conducted an unannounced Case Management Deficiencies inspection to address deficiencies observed during another complaint inspection. LPAs conducted a walk through of the facility and LPAs observed a resident's insulin medication in a refrigerator located in the garage stored with resident food and and not secured from other resident access. LPA observed the door to the closet only has dead bolt lock which can be opened by any resident, LPA inquired if facility has a key to lock the lower handle and Licensee did not have access to a key to lock the garage door and make inaccessible to residents in care. LPA observed a lock box provided to the facility and maintenance was on site to address locking doors. Per California Code of Regulations, Title 22 the following deficiency is cited. Exit Interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Mar 14, 2025

Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by, LPAs observations of insulin medication being stored in a fridge in the garage that was not made inacessible to residents in care wich poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: LPA observed a lock back be delivered to the facility. LPA will clear deficiency.

Type of visit: Post Licensing

On 02/13/24 at 8:42 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived met with administrator Cleopatra Gardier and explained the purpose of the visit. Administrator assisted with today’s visit. There are currently seven (7) residents currently living at the facility. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 116.3 Fahrenheit. The temperature inside the facility measured at 75 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements Resident Personal Rights, Evacuation Routes and facility license was all posted as required. LPA reviewed 4 out of 7 resident files and 2 staff files. LPA confirmed that residents’ files have the required documents. However, based on resident record review and observation it was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. As a result of this post-licensing visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Prelicensing

On 11/01/2024 at 10:08 AM, Licensing Program Analyst (LPA) Pang Lee arrived announced to conduct a Pre-Licensing follow-up inspection of the facility to ensure compliance with Title 22 regulations. LPA Lee met with Cleopatra Gardiner who assisted LPA in today’s inspection. LPA Lee toured the facility with Cleopatra Gardiner. During today's visit, all corrections were completed, and the applicant has passed the pre-licensing visit. · Licensee/Administrator will ensure that the facility has a current first aid manual. COMPLETED · Licensee/Administrator will ensure that there a new purchased fire extinguisher with receipt of purchase or a new service fire extinguisher. A copy of the receipt will be provided to the LPA upon purchase. During today's visit, LPA observed a new fire extinguisher with a receipt date of 10/30/2024. COMPLETED · Licensee/Administrator will ensure that the burst pipe is resolved and that there are no other leaks. A copy of services rendered shall be provided to the LPA upon completion. During today's visit applicant provided LPA Lee an invoice of sprinkler repair and PVC pipe repair. COMPLETED LPA reviewed Component 3 with the applicant. The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report was given to the applicant.the state’s words, verbatim · CDSS document, Nov 1, 2024

Type of visit: Prelicensing

On 10/20/2024, Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived announced to conduct a Pre-Licensing Inspection follow-up of the facility to ensure compliance with Title 22 regulations. LPAs met with applicant Cleopatra Gardiner who assisted in today’s inspection. The licensee will be the administrator to this facility. Administrator certificate number # 6069023740 and will expires on 04/15/2026. This Applicant is seeking licensure for a 14 non-ambulatory Residential Care Facility for the Elderly (RCFE) to accept and retain at any given time with a perspective of hospice waiver for two. The facility will not employ staff who are live-in caregivers but will have staff working shifts throughout the day/night for proper 24-hour care and supervision. There were no residents in care at this time. LPAs toured the facility with applicant and reviewed the facility sketch and the facility reflected the approved fire clearance STD 850 document. Applicant informed LPAs that this morning the pipe to the left of the home burst and that there is a flood on the side of the home. LPAs observed a maintenance guy working on the pipe. LPAs also observed the same fire extinguisher that was brought to the facility on 10/10/2024 from Diana Garcia with the service tag of 08/14/2024 and as a new extinguisher by Sacramento Fire Extinguisher Company with the Cert Reg. No. 7616 with the same signature. During today’s visit, the following corrections were not completed and must be corrected: · Licensee/Administrator will ensure that the facility has a current first aid manual. · Licensee/Administrator will ensure that there a new purchased fire extinguisher with receipt of purchase or a new service fire extinguisher. A copy of the receipt will be provided to the LPA upon purchase. · Licensee/Administrator will ensure that the burst pipe is resolved and that there are no other leaks. A copy of services rendered shall be provided to the LPA upon completion. The Applicant has not passed the pre-licensing component of the application process. The applicant will correct issues and inform LPA when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the Applicant.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Prelicensing

On 10/10/24 at 8:30 AM, Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived announced to conduct a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPAs met with applicant, Cleopatra Gardiner. Licensee assisted LPAs in today’s inspection. This Applicant is seeking licensure for a 14 non-ambulatory Residential Care Facility for the Elderly (RCFE) to accept and retain at any given time with a perspective of hospice waiver for two. This facility will also have a dementia plan on file. The facility will not have live in staff and will provide 24/7 care to residents. There were no residents at this time. A brief interview with applicant Gardiner was conducted. Cleopatra Gardiner will be the Administrator of this facility. The facility administrator’s certificate # is 6069023740 and will expire 04/15/2026. Per Guardian and LIC 500 Personnel Report, the proposed administrator Cleopatra Gardiner to this pending facility is also associated to two other facilities Love and Comfort Elderly Care and Vita Bella Elderly Care III as the administrator. The facility has an infection control plan and an emergency disaster plan completed and provided to Licensing for approval. LPAs toured the facility and inspected the kitchen area. Cabinets and drawers were opened and reviewed at this time. Silverware, plates, and utensils were observed to be sufficient to meet the needs of the residents at this time. Knives were observed to be made inaccessible to the residents at this time. The food storage unit, facility refrigerator, was observed to be functional and in good repair at this time. Food supplies were reviewed for adequate 2-day perishables and 7-day non-perishable quantities, and they both were observed not sufficient at this time. LPAs observed 37 cans of various canned goods, a pack of 6 instant ramen, 4 packs of spaghetti noodles, a container of quick oats, macaroni and cheese, cereal and 12 cans of Pepsi Soda. LPAs observed cleaning supplies and laundry supplies were made accessible to the residents at this time. Cleaning and laundry supplies were stored inside the washer such as Clorox, window, tide, and fabric softener. The common area and dining area were observed to be furnished and not sufficient to seat and meet the needs of the 14 residents at this time. LPAs observed 6 seats around the dining table with no additional seating. LPAs observed a telephone made available to residents in the kitchen. The facility smoke detectors and carbon detectors were observed to be in good condition. The fire extinguisher was last serviced on 10/10/2023. LPAs observed two additional fire extinguishers on the kitchen counter; however, administrator were not able to locate the receipt of purchased. At 9:40 AM, it was learned that a care staff Diana Garcia from Vita Bella Elderly Care II came to the facility to drop off a fire extinguisher that was last service on 08/14/2024 as a new extinguisher by Sacramento Fire Extinguisher Company with the Cert Reg. No. 7616. Linen closet was observed and had sufficient supply of sheets, bedding, pillowcases, and blankets to meet the needs of the residents at this time. Residents’ bedrooms were toured, and furniture and furnishings were observed to be sufficient and able to meet the needs of the residents. A tour of the staff bedroom was conducted. LPAs observed that there was not a door that would ensure that the stairs were inaccessible to the residents in care. LPAs observed a mattress on the floor. The water temperature measured in 3 bathrooms were conducted. Bathroom one had water temperature of 137.5 degrees Fahrenheit, bathroom 2 had a water temperature of 135.5 and bathroom 3 had a water temperature of 65.8. The facility temperature measured at 67.1 degrees. LPAs observed the centrally stored medication areas to be locked. LPAs inspected the first aid kit, and it was not complete. First Aid kit was missing a thermometer and A current edition of a first aid manual approved by the American Red Cross. LPAs observed there were sufficient supply of hygiene items on the premises made available to residents in care. LPAs observed facility has a designated area for residents and staff files, which is kept locked. LPAs also observed required posters posted. LPAs did observe>? activity supplies made available for residents at this time. LPAs toured the garage and observed miscellaneous items stored in the garage. LPAs advised administrator that the piles of miscellaneous items will need to be declutter and cleaned up. LPAs toured the courtyard and did not observe the courtyard having sufficient furniture made available for residents in care at this time. LPAs observed the courtyard to be hazardous with exposed wires, wood planks, shatter glasses and outgrown shrubs and tree branches. It was also observed two exit gates in the courtyard are not self-closing or latching. LPAs discussed with the applicant that the following items must be corrected: · Licensee/Administrator will ensure to declutter and clean out the miscellaneous in the garage. · Licensee/Administrator will ensure that the facility have sufficient supplies of 2 days perishable and 7 days non-perishable for 14 residents in care at all times. · Licensee/Administrator will ensure that all chemicals/toxins are made inaccessible to residents. · Licensee/Administrator will ensure that the facility has a first aid kit including a thermometer and a current first aid manual. · Licensee/Administrator will ensure that there is a serviced fire extinguisher at all times. · Licensee/Administrator will ensure that there is sufficient seating in the courtyard made available to residents. · Licensee/Administrator will ensure that all the exposed wires, wood planks, shatter glass and outgrown shrubs and tree branches are cleaned and discard. The Applicant has not passed the pre-licensing component of the application process. The applicant will correct issues and inform LPA when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided to the Applicant.the state’s words, verbatim · CDSS document, Oct 10, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 14 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Cleopatra Gardiner, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming date of birth. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 13, 2024