Legacy Senior Care II

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit. LPA met with caregiver and explained purpose of the visit. Today's visit, there was one care giver for five residents in care. One resident was out of the facility during LPA's visit. During today's inspection LPA toured the facility and observed resident rooms, common areas, kitchen, outdoor area, and staff area. LPA observed two residents in the common area, and three residents in their bedrooms. LPA observed facility to be clean and free of malodor. LPA observed Administrator Certificate posted to be expired. Updated certificate was printed and provided to facility to post in the common area. As a result of today's visit, no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Licensee/staff member was under the influence of alcohol while present in the facility, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care. Staff are allowing people to enter the facility to sell residents illegal drugs. Staff are allowing residents to consume illegal drugs.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint allegations. LPA met with Adilina Tuiloma during today’s inspection. The department investigated allegation, “Licensee/staff member was under the influence of alcohol while present in the facility, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.” The department interviewed residents and staff and toured the facility. During interviews with resident, it was determined they have not smelled alcohol on caregiver or seen staff drinking at the facility. LPA toured facility and did not observe alcohol within the facility. Due to the information gathered, the department finds allegation unfounded. The department investigated allegation, “Staff are allowing people to enter the facility to sell residents illegal drugs.” The department interviewed residents and staff and toured the facility. During interviews with residents, it was reported they have not observed resident’s taking drugs or possessing drug paraphernalia. Continuation on 9099-C. Unfounded In addition, resident has not observed individuals selling drugs to other residents. LPA toured the facility and did not observe drug paraphernalia, and no one seemed under the influence of drugs or alcohol. Due to the information gathered, the department finds allegation unfounded. The department investigated allegation, “Staff are allowing residents to consume illegal drugs.” The department interviewed residents and staff and toured the facility. During interviews with residents, it was reported they have not observed resident’s taking drugs or possessing drug paraphernalia. LPA toured the facility and did not observe drug paraphernalia, and no one seemed under the influence of drugs or alcohol. Due to the information gathered, the department finds allegation unfounded. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of report provided. LPA spoke to a fire department representative and reviewed incident calls at the facility address. Representative stated there were no calls of service in April 2026. However, in March 2026, there was one call that occurred at 3:30 AM in which R1 fell and called 911 themselves. It was documented that when the fire department personnel arrived, R1 was accompanied by a caregiver and a housemate. Due to the information gathered, LPA finds allegation unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 59-AS-20260520151638

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with caregiver Adilina Tuiloma during today's visit. Upon arrival there was 1 caregiver available until 10 am when a 2nd caregiver arrived. During today's inspection LPA toured the facility and observed resident rooms, common areas, kitchen, outdoor area, and staff area. LPA reviewed 6 of 6 resident files. LPA reviewed 6 of 6 resident medications comparing with physician orders and current MARS. During today's visit, no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: The facility allowed excluded individuals to work in the facility. Staff are forging resident documents. The Administrator is not present at the facility for a sufficient amount of time.

Licensed Program Analyst (LPA) Cassandra Mikkelson and Kerry Hiratsuka arrived at the facility unannounced and met with Adi Lina Tuiloma to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded The facility allowed excluded individuals to work in the facility. Documents reviewed indicated that all staff present at the facility and currently listed on the staff roster are fingerprint cleared and associated to the facility. Interviews conducted with Administrator indicated that there are no uncleared staff at the facility and Administrator explained how she conducts hiring and fingerprinting staff prior to start date at the facility. Therefore, the allegation the facility allowed excluded individuals to work in the facility is unfounded. Staff are forging resident documents. Documents reviewed indicated that all physician signatures were from separate physicians and matched other signatures in each resident specific files. All resident files included all documents to meet regulatory requirements. In review of the staff files, signatures and printed names matched each staff file. Therefore, the allegation staff are forging resident documents is unfounded. The Administrator is not present at the facility for a sufficient amount of time. Observations made on unannounced visits by the Department made on 01/08/2026 and 11/04/2025 which indicated that the facility’s administrator was present at the facility. Documents reviewed indicated that a current staff schedule is being followed and is accurate to current staff working. Therefore, the allegation the administrator is not present at the facility for a sufficient amount of time is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20260212170025

Allegation investigated: Insufficient staffing Facility is not arranging transportation to doctors appointments Medication mismanagement Facility not providing a safe environment Resident has wandered away from the facility

Licensed Program Analyst (LPA) Cassandra Mikkelson and Kerry Hiratsuka arrived at the facility unannounced and met with Adi Lina Tuiloma to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated Insufficient staffing Records reviewed indicated that staff have adequate training. Review of staff schedule indicated that there are staff scheduled to work to meet the residents in care needs. Interviews with Administrator, staff and residents indicated that staff are able to complete their daily tasks and assist all residents in care with their needs. Therefore, the allegation insufficient staffing is unsubstantiated. Facility is not arranging transportation to doctors appointments Interviews conducted indicated that administrator was assisting in scheduling transportation for doctors appointments. There were a handful of times that the third party transport company cancelled last minute causing the resident to miss their scheduled appointment. Administrator or facility staff are able to assist with taking residents to their appointments. Therefore, the allegation facility is not arranging transportation to doctors appointments is unsubstantiated. Medication mismanagement Records reviewed indicated that sodium tablets were prescribed but then discontinued in November 2025 by Resident R1’s primary care physician (PCP). Facility was using an updated medication list signed by R1's physician as reference to the medications given. Facility accurately discontinued the medications as requested by PCP. Interviews conducted indicated that resident R1 was willing and able to take their medications and does not have any refusals of medications. Therefore, the allegation medication mismanagement is unsubstantiated. Facility not providing a safe environment Records reviewed indicated that R1 and R3 were in a verbal altercation on 11/16/2025. No injuries were noted per incident report. Interviews indicated that staff are providing a safe environment for residents in care. Observations indicated that residents are safe and being taken care of by staff at the facility. Therefore, the allegation of facility not providing a safe environment is unsubstantiated. ** continued on 9099-C2 page** Resident has wandered away from the facility Records indicated that there have not been any elopements from the facility. Resident R4 is considered an unsafe wandering risk but has not left the facility unattended while is care. Interviews conducted indicated that there have not been any elopements from the facility. Therefore, the allegation resident has wandered away from the facility is unsubstantiated. Resident's personal items were not safeguarded Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. Therefore, the allegation resident's personal items were not safeguarded is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Facility does not have sufficient food Observations made indicated that facility has the required two day perishable and seven day non-perishable food supply on hand. Meals are provided and portion sizes are adequate. Interviews conducted indicated that meals are served three times a day and residents can request secondary portions of meals if they would like. Therefore, the allegation facility does not have sufficient food is unfounded. Resident's personal items were not safeguarded Interviews conducted indicated that when resident R1 moved out of the facility 02/03/2026, their personal belongings remained at the facility until 03/11/2026. On 03/11/2026, R1’s belongings were picked up, although one box was left behind by mistake. R1’s family contacted administrator and requested the missing items and they were found and belongings were given back to R1 and their family. Therefore, the allegation resident’s personal items were not safeguarded is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 59-AS-20251231122726

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA)s Hiratsuka and Mikkelson, conducted this announced annual visit. LPAs toured with Caregiver Manoa Namusudroka. Administrator Adilina Tuiloma arrived during visit. This facility currently has five residents. There are two shared and two private resident rooms. There is one full shared bathroom and one full bathroom in one of the shared resident rooms. A couple of resident rooms have exits to the outside. There is a locked laundry room and a staff room that is located by the kitchen. The dining, common, and kitchen areas were clean during this visit. There are two sheds in the backyard that are used for storage. There is a locked closet for medications and files. There are locked cabinets for cleaning toxins and sharps. Five of five resident records were reviewed. Six staff files were reviewed. Discussed with Administrator is logging of staff training. The staff do have training but some have logs that have dates, times, topics, and the length of time and some just have the training topics with the sheets signed. Staff do have training, but the logs are required to have the dates, times, topics, and length of time. The front gate was discussed. The gate is able to be opened but it can be difficult. Administrator stated she contacted a maintenance person and landlord about the gate to get it fixed or replaced. LPAs discussed leaving it partially open during the day time hours and close it at night without locking the gate. Resident supervision and audio alerts were discussed. Several other topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Case Management - Incident

On February 12, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a follow-up case management visit regarding LPA's visit conducted on January 8, 2026. LPA met with staff and explained the purpose of the visit. Staff contacted Administrator who informed LPA that she was unavailable to meet in person as she is occupied for an assessment at a different facility. During LPA's visit conducted on January 8, 2026, the visit was regarding a death report LPA received which was reported late to Community Care Licensing. Interview was conducted with Administrator on January 8, 2026, which revealed that R1 was observed to be declining for a "couple" of weeks. Observations was reported to R1's responsible party but not to R1's primary care physician. Additionally, file review was conducted which revealed that R1 is on a special diet of pureed textured nectar thick, but this special diet was not followed as R1 did not like the texture. Interview conducted with Administrator and staff conducted on January 8, 2026 revealed that day of R1's death, R1 was provided eggs and scrambled eggs for breakfast. It was discussed over the phone with Administrator when a resident has a change of condition it is to be documented and reported immediately to primary care physician. Additionally, it was discussed over the phone with Administrator that if a special diet was ordered by a physician, facility is to follow and/or report to physician if there is any concerns where the special diet cannot be met. As a result of today's visit, deficiencies were cited. Please see LIC 809-D. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 13, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, Licensee failed to notify R1's primary care physician of R1's change of condition as R1 was not eating as much and sleeping more, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee is to create Administrator and caregiver's responsibility of resident observations and identify what steps are to be taken. POC can be submitted to LPA: email:cassie.yang@dss.ca.gov or cclascpsacramentonorthro@dss.ca.gov and/or fax to 916-263-4808 The plan of correction is due within 24 hours on February 13, 2026. Failure to correct by due date may result to an additional civil penalty of $100 per day until received.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(7) · Plan of correction due date: Feb 13, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on file review and interviews conducted, Licensee failed to comply as R1 was ordered special diet of pureed textured, nectar thick consistency, fortified diet on May 19, 2025, but facility did not give R1's the followin special diet as R1 did not like it which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee is to conduct an audit of resident records and establish the residents' special diets ordered by physician. POC should include resident names, special diets, and menu examples. POC can be submitted to LPA: email:cassie.yang@dss.ca.gov or cclascpsacramentonorthro@dss.ca.gov and/or fax to 916-263-4808 The plan of correction is due within 24 hours on February 13, 2026. Failure to correct by due date may result to an additional civil penalty of $100 per day until received.

Type of visit: POC

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding a deficiency that was cited on January 8, 2026. LPA met with staff and explained purpose of the visit. Today's visit, LPA cleared the following deficiency as POC was received on January 22, 2026 within the POC due date. 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. POC letter was generated and provided. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Cassie Yang and Kevin Mknelly arrived at the facility to conduct a case management visit regarding an incident that LPAs were made aware of during LPAs' visit. LPA met with Administrator and explained the purpose of the visit. Upon LPAs' arrival, LPAs were informed that today's census was five (5) residents in care as resident (R1) had recently passed away in the month of December 2025. File review was conducted and observed that R1 was not on hospice services. Administrator stated death report was submitted but to the wrong regional office. LPA was provided a copy of R1's death report. File review revealed R1 passed away December 18, 2025 but death report was not submitted to Licensing until December 29, 2025. LPAs and Administrator discussed the importance of submitting death reports in a timely manner within the seven days of occurrence. At this time, this matter remains under review by the Department. Deficiencies cited. As this is a repeated violation, an additional $250 civil penalty has been assessed. Exit interview conducted and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jan 22, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Based on file review and interview, Licensee failed to comply as death report was not submited to Licensing until 11 days after occurrence, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: Licensee is to create and submit to Licensing a reporting requirement policy procedure for facility to ensure incidents are reported in a timely manner. email:cclascpsacramentonorthro@dss.ca.gov and/or fax 916-263-4808 This is a repeated violation, a $250 civil penalty will be assessed. The plan of correction is due January 22, 2026. Failure to correct by due date may result to an additional civil penalty of $100 per day until received.

Type of visit: Case Management - Other

On November 4, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management visit. LPA met with Administrator and explained the purpose of the visit. During LPA's previous visit conducted on Thursday October 30, 2025, LPA removed R1's file from the facility to produce copies. Facility was informed file shall be returned within three business days. Today's visit, LPA returned R1’s complete file that was removed from the facility on Thursday, October 30, 2025. No deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction visit regarding a deficiency cited on October 30, 2025. LPA met with staff then Administrator arrived to the facility afterwards. LPA explained the purpose of the visit. On October 30, 2025, LPA observed a staff member without a criminal record clearance to be working at the facility. Type A deficiency cited with plan of correction due date to be October 31, 2025. Plan of correction of, Licensee is to submit a statement of compliance, understanding that prior to any staff and/or volunteers working and residing at the facility, a criminal record clearance needs to be granted, was submitted late to LPA on November 3, 2025. Today’s visit, a civil penalty of $300 for failure to correct was issued. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Deficiencies

On November 4, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding a deficiency observed on November 3, 2025. LPA met with and explained the purpose of the visit. On November 3, 2025, LPA contacted the facility and spoke with S1. LPA was informed S1 is working alone at the facility. File review was conducted, and determined that S1 does not have a criminal record transfer associated with the facility. LPA and Administrator discussed that prior to working, residing, or volunteering at the facility, all individuals need a granted criminal record clearance and/or exemption, and their clearance is to be associated with their facility roster. A facility’s roster was provided to the facility on October 30, 2025. Additionally, today's visit, LPA provided a facility roster to emphasize the individuals who are cleared to work at the facility. Today’s visit, LIC 9182 was provided and completed for S1 to work at the facility. LPA completed the Guardian association and provided an updated Guardian roster. LPA informed Administrator that in the future all individuals are to be associated with the facility, which can be done via Guardian. If Administrator does not have access to Guardian, they can be reach at Guardian@dss.ca.gov to regain access. Meanwhile, Administrator is able to submit a completed LIC 9182 and a copy of driver’s license or identification card and fax the following to 916-263-4808 or email the following to sacasctransferrequest@dss.ca.gov Today’s visit, deficiencies cited. Please see LIC 809-D. Exit interview, Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(2) · Plan of correction due date: Nov 5, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on file review, interview and observation, LPA observed S1 to be living at the facility without a criminal record transfer to the facility, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: LIC 9182 completed and criminal record transfer initiated by LPA. Licensee is to conduct an audit of facility roster to ensure all staff are associated with the facility. Licensee is to notify LPA once completed. POC is due within 24 hours on November 5, 2025. Failure to correct by POC due date may result to a civil penalty of $100 per day until received.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Nov 12, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified...If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. Based on observation and interview, Licensee did not comply as the appointed Administrator failed to comply with criminal record clearance regulations twice within a week which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee is to conduct an in-service training for appointed Administrator on PIN 24-02-CCLD to ensure facility is compliance to all criminal record clearance regulations. In-service must be conducted within a week by November 12, 2025. . Licensee is to notify LPA once completed. POC is due on November 12, 2025. Failure to correct by POC due date may result to a civil penalty of $100 per day until received.

Type of visit: Case Management - Incident

On October 30, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding an incident that occurred on October 9, 2025. LPA met with staff and explained the purpose of the visit. Today's visit, LPA was informed Administrator is unavailable due to an emergency. Today's visit, LPA obtained resident 's (R1) whole file. In accordance to: 87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: (3) Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed. LPA may return R1's file within three business days by Tuesday November 4, 2025. This matter is still under review by the Department. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding a deficiency observed. LPA met with staff and explained the purpose of the visit. Today's visit, LPA was informed Administrator is unavailable due to an emergency. Upon LPA's visit, LPA observed staff (S1) to be working at the facility. When asked S1 confirmed S1 has been living at the facility since Monday October 27, 2025. File review on Guardian, LPA observed that S1 has a status of "in process" for fingerprint clearance. LPA informed staff that all individuals working, volunteering and residing at the facility will need a criminal record clearance prior to initial presence at the facility. A copy of facility's current Guardian roster was provided to staff to confirm that S1's criminal record clearance is still pending. Today's visit, deficiencies cited. Please see LIC809-D. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Oct 31, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as S1 has been residing at the facility since October 27, 2025 without a criminal record which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: S1 is to vacate the facility immediately, S1 may return when clearance is granted. Licensee is to submit a statement of compliance, understanding that prior to any staff and/or volunteers working and residing at the facility, a criminal record clearance needs to be granted prior. POC is due within 24 hours on October 31, 2025. Failure to correct by POC due date may result to a civil penalty of $100 per day until received.

Type of visit: Case Management - Legal/Non-compliance

On October 9, 2025, Licensing Program Manager (LPM) Troy Ordonez and Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with staff who then contacted Administrator who arrived to the facility. During today's visit, LPM and Administrator conducted a tour of the facility to ensure the health and safety of residents in care. Storage space was inspected to confirm medications, toxins and sharps are locked and secured. LPM observed facility to be unsanitary as feces was observed to be on the the door and walls of the facility. LPA and LPM conducted a file review of residents in care and discussed the following concerns with Administrator. As a result of today's visit, deficiencies observed. Please see LIC 809-D. Copy of report and appeal rights provided during exit interview.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(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 is not met as evidenced by: Based on observation, Licensee did not comply as it was observed that there was feces on the doors and walls, which poses a risk for residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Licensee is to have facility to be cleaned immediately. Additionally, Licensee to submit a statement of understanding that if facility wishes to retain incontinence residents, facility needs to remain clean and sanitary at all times. Plan of correction is due October 10, 2025 to LPA Yang via email at cassie.yang@dss.ca.gov Failure to provide plan of correction by due date will result to $100 civil penalty per day until received.

Type of visit: Office

A Non-Compliance Conference office meeting was held on September 25, 2025, at Sacramento Regional Office with the Licensee Adi Lina Tuiloma and facility representative Una Phyllis to discuss the deficiencies found at the facility and the actions needed to bring the facility into compliance with Title 22 regulations. Present in the meeting were Community Care Licensing (CCL) staff, including Regional Manager Alycia Rayner, Licensing Program Manager Troy Ordonez, Licensing Program Manager Laura Munoz, Licensing Program Manager Stephen Richardson, Licensing Program Analyst Cassie Yang, Licensing Program Analyst Cheyenne Ratajczak and Licensing Program Analyst Christina Valerio. During the meeting, CCL reviewed the facility’s history of citations, including Type A and Type B violations since April 2025. The citations involved issues such as fire safety, reporting requirements, resident records, administrator oversight, and reporting requirements. CCL stressed the importance of taking immediate corrective action to ensure resident safety and meet licensing requirements. CCL expressed concern about limited administrator oversight, including the administrator’s low on-site hours, unresponsiveness to calls, and insufficient supervision of staff. Staffing levels were also noted as a concern, with coverage gaps that could put residents at risk. The licensee agreed to take specific steps to fix these issues. These actions include making sure resident rooms meet licensed capacity, providing adequate staffing at all times, increasing administrator on-site hours or designating a qualified substitute, submitting personnel reports and supervision outlines, ensuring medications are available and administered on time, and conducting safety checks to secure chemicals and equipment. Please continue on LIC 809-C. LIC 809-C Licensee was provided a copy of Hospice Guide, Medication Guide, and Self-Assessment Guide. Additionally, CCL will submit a referral for technical support program. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: POC

On September 16, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a Plan of Correction visit regarding the deficiency cited on August 28, 2025. LPA met with staff and explained the purpose of the visit. On August 28, 2025, it was observed that the facility’s fire door was left open for residents to pass by freely. The purpose of the fire door is to comply with 2022 CALIFORNIA FIRE CODE: 435.8.3.2 Group R-3.1 occupancies housing non-ambulatory clients: In a Group R-3.1 occupancy, bedrooms used by non-ambulatory clients shall have access to at least one of the required exits, which shall conform to one of the following: 1. Egress through a hallway or area into a bedroom in the immediate area which has an exit directly to the exterior and the corridor/hallway is constructed consistent with the dwelling unit interior walls. The hallway shall be separated from common areas by a solid wood door not less than 13/8 inch (35 mm) in thickness, maintained self-closing OR shall be automatic closing by actuation of a smoke detector installed in accordance with Section 716.5.9. 2. Egress through a hallway which has an exit directly to the exterior. The hallway shall be separated from the rest of the house by a wall constructed consistent with the dwelling unit interior walls and opening protected by a solid wood door not less than 13/8 inch (35 mm) in thickness, maintained self-closing or shall be automatic closing by actuation of a smoke detector installed in accordance with Section 716.5.9. 3. Direct exit from the bedroom to the exterior shall be of a size as to permit the installation of a door not less than 3 feet (914 mm) in width and not less than 6 feet 8 inches (2032 mm) in height. When installed, doors shall be capable of opening at least 90 degrees and shall be so mounted that the clear width of the exit way is not less than 32 inches (813 mm). 4. Egress through an adjoining bedroom which exits to the exterior. Please continue on LIC 809-C. LIC 809-C The plan of correction of Licensee is to submit a plan to LPA if facility wishes to install a magnetic door opener; if not, then Licensee needs to submit a plan of how facility will ensure fire door remains closed – was due on September 2, 2025. Additionally, LPA contacted Licensee on September 8, 2025 as a reminder that POC was due. As of the date of visit, LPA has not received plan of correction. Failure to correct civil penalty has been assessed of $100 per day. Civil penalty will continue to accrue $100 per day until plan of correction is received. Exit interview, a copy of report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding a deficiency LPA observe. LPA met with staff and explained the purpose of the visit. Additionally, LPA spoke with Administrator via telephone to discuss the concerns observed. Upon arrival, LPA observed the front gate to be in disrepair. LPA contacted facility telephone and spoke with staff. Staff then met LPA at the gate. LPA and staff attempted to realign the gate for LPA to enter the facility; however, LPA then observed residents in care needing assistance with redirecting. LPA was informed there is only one caregiver working at the moment. LPA contacted Licensee who informed LPA front gate has been in disrepair since last week but mechanic was unavailable to come to the facility to fix it. When asked, Licensee stated staff informed Licensee of the gate on Wednesday September 10, 2025. LPA informed Licensee the following deficiency is a fire safety concern as facility is not appropriate for locked perimeters, and there is no way for residents to exit and/or reenter. LPA observed the gate to extend to approximately 8 to 10 inches only. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Additionally, immediate civil penalty of $1000 was accessed today as fire safety violation is a repeated violation. Plan of correction due today. Failure to correct may result to additional $100 per day until plan of correction is received. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Sep 16, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, Licensee failed to comply as facility front gate was in disrepair where it was unable to open for residents to exit which poses an immediate danger for residents in care,the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: -Licensee is to submit proof of front gate to be fixed and operating. -Additionally, Licensee is to submit a plan of how Licensee will ensure front gate is always in working condition for residents to exit. Plan of correction is due today September 16, 2025. Failure to correct may result to additional $100 civil penalty until corrected.

Type of visit: Case Management - Other

On August 28, 2025, Licensing Program Analyst (LPA) Cassie Yang conducted unannounced case management visit. LPA met with caregiver who stated Administrator is not at the facility at this time. When asked, LPA was informed Administrator has not been at the facility since last week. This visit is to deliver in-person of ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY. Facility understands this is an Immediate Exclusion and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit when LPA observed a deficiency. LPA met with caregiver and explained the purpose of the visit. Today's visit, LPA observed facility fire door to the residents bedrooms to be hooked opened. LPA informed caregiver that all fire doors are to be closed at all times as per State Fire Marshal. Caregiver immediately unhook the fire open during LPA's visit. LPA informed Caregiver if wished to keep door opened, magnetic door opener is to be properly installed. Deficiencies cited. Please see LIC809-D. Exit interview, copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Sep 2, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, Licensee did not comply as LPA observed fire door to be hooked opened which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Hook was immediately removed by caregiver. Licensee is to submit a plan to LPA if facility wishes to install a magnetic door opener, if not, then Licensee needs to submit a plan of how facility will ensure fire door remains closed.

Type of visit: Case Management - Other

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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 15, 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 in this section... This requirement is not as evidenced by: Based on observation, Licensee did not comply to the section cited above as LPA contacted facility via phone call and email on July 7, July 8 and July 9 for R1's admission agreement to be submitted to the Department but did not receive a response, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee is to submit to LPA LIC500 with date and time that Administrator is present at the facility. Additionally, Licensee will submit a written plan for the duties and task to be completed when present to ensure compliance with Title 22 requirements. POC is due July 15, 2025. Failure to correct by due date may result to civil penalty.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Jul 15, 2025

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requirement is not met as evidenced by: Based on file review, Licensee failed to comply as LPA arrived to retrieve a copy of R1's admission agreement but file was unable to be relocated, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee is to submit a statement of understanding that resident records should be safeguarded and stored for minimum of three years. Additionally, Licensee is to submit a plan of how facility will handle records to ensure no files goes missing. POC is due July 15, 2025. Failure to correct by due date may result to civil penalty.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jul 15, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency...(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidenced by: Based on file review, Licensee failed to comply as LPA did not received a death report for R1 who passed away over two weeks ago, which poses a risk for residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee is to review the reporting requirements and submit a statement of understanding. Additionally, Licensee is to submit LIC624A for R1 to LPA by July 15, 2025. POC is due July 15, 2025. Failure to correct by due date may result to civil penalty.

Type of visit: POC

On May 20, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit regarding two deficiencies that was cited on April 25, 2025. LPA met with caregiver who attempted to contact Administrator who was unavailable. Today's visit, LPA explained that POCs has not been received yet, copies of the report with deficiencies were emailed to Administrator's email on file on April 25, 2025 at 5:26 p.m. POC were due May 9, 2025. LPA informed caregiver that Licensee is to submit the POCs as soon as possible as civil penalties will continue to accrue. 87458 Medical Assessment - POC: Licensee is to conduct an audit of residents medical assessment to confirm tuberculosis testing are conducted. Licensee is to schedule residents an appointment for tuberculosis testing if missing on file. 87211 Reporting Requirements - POC: Licensee is to review the Reporting Requirement regulation and submit a statement of compliance to LPA. POC may be submitted via fax and/or email to Sacramento North Regional Office at: Fax: 916-263-4808 Email: sacramentonorthregionalofficeascp@dss.ca.gov As a result of today's visit, civil penalties were assessed for $100 per day it has not been received. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, May 20, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection when LPA observed a following deficiency. LPA met with staff and explained the purpose of the visit. Administrator was unable to make it to this visit. Based on interview, LPA was informed today's census is three residents in care. LPA was additionally informed two residents are at the hospital for evaluation. LPA was informed R1 was sent out on April 1, 2025 and R2 was sent out on April 17, 2025. LPA was unable to locate any submitted incident reports submitted by Licensee. Deficiencies cited. Exit interview and a copy of report and appeal rights was emailed.the state’s words, verbatim · CDSS document, Apr 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 9, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as LPA was made aware that R1 and R2 are at the hospital but no incident reports observed which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2025

Plan of correction: Licensee is to review the Reporting Requirement regulation and submit a statement of compliance to LPA.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with staff and explained the purpose of the visit. Administrator informed LPA on the phone she was an hour away and unable to make it. LPA observed three residents in care with one resident on hospice services. LPA was informed two residents are at the hospital for evaluation. Facility census is compliance to license. Today's visit, LPA and staff conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, laundry room, staff room, kitchen and the common areas. LPA observed the common area to have the mandated compliance posters posted. LPA observed fire extinguisher to be recently serviced on November 5, 2024. Facility temperature was observed at a comfortable 72*F. LPA observed facility to have ample perishable and nonperishable food supply. LPA observed carbon monoxide detectors to be working and in good condition. Sharps are stored in staff room which was observed to be locked. LPA observed laundry room to be locked. Medications are stored in closet, locked and secured. Emergency Disaster Plan was observed to be reviewed and updated in 2024, pending review for 2025. File review conducted for five out of five residents in care. LPA observed R1 and R2's medical assessment present with no documentation of tuberculosis testing. As a result of today's visit, deficiencies cited. Exit interview and a copy of report and appeal rights was emailed.the state’s words, verbatim · CDSS document, Apr 25, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cheyenne Ratajczak conducted an unannounced case management visit on 11/21/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with caregiver Walesi Vakararawa and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 11/21/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Post Licensing

On May 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a post-licensing visit. LPA met with Walesi Vakarawai caregiver and informed her the reason for the visit. During the last visit, LPA noticed the washer and dryer was not placed in the area it is supposed to go. LPA informed the administrator that LPA would be back to see if it was in the area it is supposed to be. When LPA arrived a caregiver allowed entry into the home. LPA noticed the washer and dryer was in fact in the area it is supposed to be. LPA asked the caregiver how it was going and did they need anything. Caregiver said everything was going well and had no questions. The facility now has 5 residents living in the home. No known issues. Per California Code of Regulations, Title 22, no citations were issued. An exit interview was conducted and a copy of this report was given to Walesi.the state’s words, verbatim · CDSS document, May 2, 2024

Type of visit: Prelicensing

,On March 19, 2024, at 9am, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived announced to conduct a Pre-licensing inspection. LPA met with Angelina, the administrator and informed her the reason for the visit. The administrator's certificate is valid and expires 2/18/2025. The home was 65 degrees F. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to ensure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 107 degrees F. There’s appropriate lighting throughout the facility. Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 6 Bedrooms and 2 bathrooms for residents. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. First aid kit was present and included the required scissors, tweezers, thermometer and guide. To continue see 809-C.. .Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. was not present. Toxic substances, laundry and cleaning supplies are inaccessible. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit An exit interview was conducted and a copy of this report was given to Angelina.the state’s words, verbatim · CDSS document, Mar 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Name, Title Adi Lina Interview Method: Telephone interview On February 20, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. General Provisions 3. Staffing requirements & Training 4. Pre-licensing readiness / needs time to set up roomsthe state’s words, verbatim · CDSS document, Feb 20, 2024