Legacy Senior Care III

Allegation investigated: The Administrator is not present at the facility for a sufficient amount of time.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with direct care staff, Mere, and explained the purpose of the visit. Facility staff informed person who oversees the facility, Jackee, of LPAs arrival. The investigation consisted of interviews with residents, interview with staff, a review of facility records, and personal observation of the facility. Allegation: The Administrator is not present at the facility for a sufficient amount of time. On 02/17/2026, LPA Valerio did not observed Administrator Tevita Kaloulasulasu present in the facility. Administrator Tevita was also not present during 02/09/2026, 02/11/2026, 03/24/2026, and 05/11/2026 visits. Based on interviews with Licensee Adi Lina, licensee stated Tevita was the administrator but could not provide proof of Administrator being present in the facility. Continues on LIC 9099 - C... Substantiated On 03/11/2026, Administrator appointed Sera Nakalevu as the administrator. On 05/11/2026, LPA contacted Sera, which stated she is the administrator for both Vita Bella Elderly Care III and Legacy Senior Care III. LPA Valerio did not observe Sera at the facility during the 05/11/2026 visit. According to interviews with residents, they were unaware of who the administrator, Tevita Kaloulasulasu. When provided specific names, no one could identify if they knew the person. On today's visit, LPA Valerio contacted Administrator Sera Nakalevu via cell phone. LPA Valerio requested Administrator Sera send all administrator documents via email to cclascpsacramentosouthRO@dss.ca.gov As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. Allegation: Staff are forging resident documents. LPA Valerio reviewed files for Resident 1 - Resident 4. LPA Valerio was unable to confirm the validity of the signatures for LIC 602 for R1 and R2. LPA contacted the number located on R3's LIC 602. LPA was able to confirm that the name of the doctor works at the medical office indicated on the LIC 602. LPA Valerio reviewed the LIC 602 for R4. R4's LIC 602 is a scanned copy and the signed name on the last page is not legible. LPA unable to confirm or deny the signature is valid. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Aug 3, 2026 · control 27-AS-20260211105253

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 4, 2026

87405 Administrator - Qualifications and Duties (a)The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility..this requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure a certified administrator was present in the facility, which poses an immediate health, safety and personal rights riskthe state’s words, verbatim · CDSS document, Aug 3, 2026

Plan of correction: The licensee to submit 40 hour Administrator plan by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit to follow up on plan of corrections. LPA Valerio met with facility staff Mere, and explained the purpose of the visit. LPA Valerio contacted Administrator Sera Nakalevu via cell phone to request her presence in the facility. LPA Valerio was later met by Administrator Sera. LPA Valerio observed the LIC 500 posted at the facility. It was dated 03/11 - 03/30/2026. According to the LIC 500, Administrator Sera Nakalevu is scheduled to be on shift on Friday - Saturday from 7:00 AM to 7:00 PM. According to the LIC 500, Staff 1 (S1) and Staff 2 (S2) were scheduled to be on shift today from 7:00 AM to 7:00 PM. Administrator Sera Nakalevu certificate #6078424740 expires on 09/03/2027. The licensee Adi Lina previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Today, only one staff member was present when LPA arrived. LPA Valerio observed one staff, Staff 1 (S1) on shift. The facility was observed to have only one staff on shift during LPA visits on 01/16/2026, 02/09/2026, 02/11/2026, 02/17/2026, 05/11/2026, and 08/03/2026. The licensee continues to be in violation of California Code of Regulations, Title 22, Section 87205(a). A civil penalty of $100.00 per day is hereby assessed for the period of 05/12/2026 through 08/03/2026, totaling to the amount of $8,400.00 . Failure to correct may result in the continued daily assessment of civil penalties. LPA Valerio toured the facility and did not observe any health or safety concerns. Residents enjoyed fried fish, mixed green salad, and garlic bread for lunch. Residents were gardening in the front, watching television, and taking a nap. An exit interview was held with Administrator Sera Nakalevu, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit to follow up on plan of corrections and to review files for the new appointed administrator, Sera Nakalevu. LPA Valerio met with facility staff Mere, and explained the purpose of the visit. LPA Valerio observed the LIC 500 posted at the facility. It was dated 03/11 - 03/30/2026. According to the LIC 500, Administrator Sera Nakalevu is scheduled to be on shift on Friday - Saturday from 7:00 AM to 7:00 PM. According to the LIC 500, Staff 1 (S1) and Staff 2 (S2) were scheduled to be on shift today from 7:00 AM to 7:00 PM. LPA Valerio interviewed residents. According to resident interviews, they did not know S2 or the Administrator. Administrator Sera Nakalevu certificate #6078424740 expires on 09/03/2027 The licensee previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Today, only one staff member was present when LPA arrived. LPA Valerio observed one staff, Staff 1 (S1) on shift. The facility was observed to have only one staff on shift during LPA visits on 01/16/2026, 02/09/2026, 02/11/2026, 02/17/2026, and 05/11/2026. The licensee continues to be in violation of California Code of Regulations, Title 22, Section 87205(a). A civil penalty of $100.00 per day is hereby assessed for the period of 03/25/2026 through 05/11/2026, totaling to the amount of $4,800.00. Failure to correct may result in the continued daily assessment of civil penalties. LPA Valerio observed S1 interactions with residents. S1 and residents expressed that S1 made a beautiful array of food for everyone. They were very happy. One resident also reported they enjoy S1 because they dance, exercise, and have good conversations. Continues on LIC 809 - C... While writing the report, LPA Valerio was approached by a resident. Resident stated there was a huge bug in the living room and was looking for a shoe. LPA Valerio contacted S1, who was in the kitchen. S1 came and removed the bug. LPA observed the bug to be a roach or a beetle. Per California Code of Regulations (CCR) - a deficiency was observed and civil penalties were assessed. Failure to correct deficiencies may result in civil penalties. Appeal rights provided. An exit interview was held with facility staff, and a copy of this report was provided. Administrator Sera designated S1 to sign off on the report.the state’s words, verbatim · CDSS document, May 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 11, 2026

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: Based on LPA Valerio's observations, The licensee did not ensure to keep the facility clean, sanitary and free of pest for the well-being of the residents in care. This posed a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, May 11, 2026

Plan of correction: Licensee stated they will contact pest control services to come conduct a service. LPA Valerio to receive copy of proof of service and copies of pest control invoices for March, April, and May of 2026 by POC due date

Allegation investigated: Questionable Death

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived to the facility unannounced to deliver a complaint investigation. LPAs met with facility staff Mere Faletono, and explained the purpose of the visit. LPA contacted Licensee Adi Lina via cell phone and an option to leave a voicemail wait not an option. During today's visit, LPA observed one staff on shift. The following has been determined as it relates to the aforementioned allegation: Questionable Death of Resident 1 (R1) resulted from the neglect/lack of supervision from staff. On January 12, 2026, R1 was observed by the facility to show signs of weakness and was out of baseline. Home health called paramedics and transported R1 to the Emergency Room. Continues LIC 9099 - C... Unsubstantiated Based on the review of medical records, R1 remained in and out of the Intensive Care Unity during R1's admittance until 01/21/2026, when R1 was pronounced deceased. According to the death report, R1 died due to hypercapnic respiratory failure (days) due to obstructive sleep apnea due to severe obesity, and comorbidity - obesity hypoventilation. Based on the review of additional medical and facility records, R1 was on home health services for heart failure. Home health was aware of R1's sleep apnea and was in the process of addressing it with the primary care physician. Supporting records indicate R1 has change to had multiple pre-existed change to existing conditions that could have contributed to the cause of death. Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 27-AS-20260209110822

Type of visit: Office

An Office Meeting was held on March 10, 2026, at 10:00 AM via Microsoft TEAMS. Present were Licensing Program Manager Stephen Richardson (LPM), Licensing Program Analysts Christina Valerio, Reza Jamaly and Arvin Villanueva (LPAs), and Licensee, Adi Lina Tuiloma. The purpose of this meeting was to discuss facility’s failure to provide requested documentation, including staff timesheets for Administrator, Tevita Kaloulasulasu, and to address additional concerns regarding staffing expectations, payroll practices and documentation retention. Failure to provide requested documentation: It was discussed with Adi Lina the facility’s failure to provide requested documentation following an initial request made on February 9, 2026 for staff timesheets and documentation that provide proof of Administrator’s actual work hours. Despite multiple follow-ups, the requested documents had not provided within a reasonable timeframe. Per last office meeting on February 26, 2026, Adi Lina had stated she will have these documents submitted to the Department by March 2, 2026. An email reminder was sent to Adi Lina on Mach 4, 2026 but she did not respond. Adi Lina stated that she had received some recent timesheets but was still waiting for timesheets from September 2025 and October 2025. Per Adi Lina, the timesheets are typically completed by employees as hard copies when they work on their scheduled shift and are maintained in a file at the facility. However, Adi Lina stated that the hard copies for the Administrator could not be located. {1 of 3} The Department had concerns regarding the facility’s ability to maintain and produce documentation when requested by the Department. Adi Lina was informed that, as a licensee of the facility, she holds ultimate responsibility for facility operations, including maintaining staff records and ensuring that required documentation can be produced in a timely manner. A delay of one month would not be considered timely. It was also discussed to Adi Lina the importance of communication with the Department. Adi Lina was informed that if there are any barriers to providing requested documents, as a licensee, she is expected to communicate timely with the LPA and can request an extension. Adi Lina failed to respond to emails timely. Regarding administrator and payroll: Adi Lina stated that Tevita Kaloulasulasu has continuously served as the facility’s administrator since it was licensed. Adi Lina stated that Tevita is paid in cash and that no W-2 forms have been issued to him. Adi Lina stated that she has been paying him directly in cash without withholding taxes. Staffing concerns: It was discussed that prior visits to the facility, the facility appeared to have only one staff on duty during these visits, despite the requirement for two staff, based on the NCC meeting held on September 25, 2026. Adi Lina stated that she has experienced difficulties retaining staff and that some employees have walked off or called sick. Adi Lina stated that when this occurs, she goes to the facility and serve as a second staff. Administrator work schedule: Adi Lina stated that Tevita is scheduled at this facility on Mondays, Wednesdays, and Fridays from 7am to 7pm. Adi Lina explained that Tevita is expected to be at this facility during scheduled time, unless there is a change and Tevita will come the following day. {2 of 3} The licensee agreed to the following: Adi Lina will submit all available timesheets for Tevita by close of business day today. Adi Lina will provide the remaining timesheets for September and October by Friday, March 13, 2026. Adi Lina will submit a written plan outlining how the facility will improve documentation retention and accessibility, including procedures to ensure that requested documents can be produce in a timely manner. Adi Lina will submit an updated LIC500 Personnel Reports for each facility operated by her, identifying the staff currently assigned to each facility. Adi Lina will ensure the facility maintains two staffing ratio in accordance with the NCC meeting. The Department will do the following: The Department will continue to conduct quarterly monitoring visits to this facility. Adi Lina was informed that failure to comply with documentation requests and staffing requirements may result in further enforcement action. Based on today’s meeting, deficiencies are being cited. Exit interview was conducted with Adi Lina, who acknowledged the discussion and the expectations outlined above. A copy of this report and appeal rights were provided via email with a request for signature and confirmation of read receipt. {3 of 3}the state’s words, verbatim · CDSS document, Mar 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Mar 13, 2026

Inspection Authority of the Licensing Agency: The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours This requirement is not met as evidenced by: Based on interviews, the licensee has not provided the requested records as of today, after several attempts to request these records for a period of approximately one month. This poses a potential health, safety, and personal risks to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2026

Plan of correction: Per disucsison, licensee Adi Lina agreed to submit a written plan outlining how the facility will improve documentation retention and accessibility, including procedures to ensure that requested documents can be produce in a timely manner. Plan must be submitted by POC due date.

Type of visit: Office

An office meeting was held on February 26, 2026, at 1400 hours via TEAMS. Present were Licensing Program Manager Stephen Richardson (LPM), Licensing Program Analysts Christina Valerio and Arvin Villanueva (LPAs), and Licensee Adi Lina Tuiloma. The purpose of this meeting was to discuss administrator updates and to request required documents. During the meeting, Adi Lina stated that the current administrator, Tevita Kaloulasulasu, has been paid in cash, which is why she is unable to provide the Department with the requested paystubs. The Department also requested documentation verifying that Tevita Kaloulasulasu has been working at the facility as the administrator since the facility’s licensure on September 16, 2025. Adi Lina agreed to submit the requested documents by March 2, 2026. Prior to the meeting, Adi Lina reported an emergency situation and requested to reschedule. The next meeting was scheduled for Tuesday, March 10, 2026, at 1000 hours via TEAMS. An exit interview was conducted, and a copy of this report was provided via email with a request for signature.the state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Christina Valerio was present today, February 17, 2026, in the facility for a subsequent visit, Complaint 27-AS-20260211105253. On February 09, 2025, LPA Valerio cited the facility for 87205(a) with a plan of correction due on 02/16/2026. LPA did not hear from Licensee Adi Lina Tuiloma regarding an extension or a reason for not submitting the plan of correction. During today's visit, there was only one staff on shift. The licensee previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Licensee Adi Lina Tuiloma was notified that daily civil penalties of $100 will start accruing on February 17, 2026 until the plan of correction is cleared. Licensee was notified via cell phone. Licensee gave permission for staff to sign on her behalf. An exit interview was held with facility staff, and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 17, 2026

Type of visit: Case Management - Other

On 2/11/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct a case management visit. LPA met with staff on duty, Mere Faletono (S1) and stated the purpose of the visit. The Licensee, Adi Lina Tuiloma, was notified. Adi Lina is unable to come to the facility at this time and appointed S1 to sign this report. Present during this visit were 4 residents in care with one staff on duty. An interview was conducted with S1. On 2/3/2026, LPA received a notification from staff (S2) stating that S2 is no longer the administrator and/or staff for this facility and wished to be disassociated from this facility. On 2/4/2026, LPA received a notification from S2 informing LPA that S2 talked to the licensee, Adi Lina Tuiloma, to disassociate S2 from this facility by 2/6/2026. On 2/9/2026, LPA followed-up with S2 regarding S2's status because per Guardian, S2 is still associated to the facility. S2 informed LPA that S2 has not worked at the facility since the pre-licensing visit on 9/2/2025. S2 stated S2 left after the pre-licensing. On 2/9/2026, LPA spoke with Adi Lina over the phone, She informed LPA that S2 is still the designated administrator. By email, LPA requested from Adi Lina documents pertaining to S2's employment status including pay stubs, timesheet and any evidence to support S2 still employed at this facility. LPA did not receive a confirmation from Adi Liina that she reveived LPA's requests until 2/11/2026. At this time, it is unclear if this facility is operating without an administrator. Further investigation is needed. During this visit, LPA obtain copy of Personnel Report (LIC500) record from 11/2025, 12/2025 and 2/2026; 1/2026 is missing. LPA also obtained copy of S2's personnel documents. LPA spoke with Adi Lina over the phone and she stated she will submit the requested documents to LPA by Friday, 2/13/2026. At this time, this case management will require a continuation. Exit interview was conducted with S1 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christina Valerio was at the facility on a subsequent visit for a complaint visit (Control Number 27-AS-20260209110822). Upon arrival, LPA Valerio rang the door bell twice and knocked on the door twice, but there was no answer. LPA Valerio contacted Licensee Adi Lina Tuiloma via cell phone who contacted staff on shift. Staff stated they were in the restroom when LPA was at the door. LPA Valerio was met by facility staff Mere. LPA Valerio informed Licensee the purpose of the visit. Licensee stated she was assisting with an appointment and thirty minutes away. LPA informed Licensee LPA will wait for her arrival. LPA was later met by Licensee. The licensee previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Today, only one staff member was present when LPA arrived. LPA Valerio observed one staff, Staff 1 (S1) on shift. According to an interview with staff, the second staff (S2) will arrive at 7:00 PM. Later, LPA Valerio interviewed Licensee Adi Lina. Licensee stated S2 is currently an on-call staff and not a regular staff. LPA Valerio reviewed the facility LIC 500, which is dated 12/01/2025. According the LIC 500, S2 was to be on shift with S1. Licensee stated the second staff member was supposed to be her; however, she had to assist with an appointment for her other licensed facility. LPA Valerio was provided an updated LIC 500 by Licensee Adi Lina during today's visit. Per California Code of Regulations (CCR), Title 22, a deficiency is being cited on the attach LIC 809 - D page. Licensee was previously cited on January 16, 2026 for having only one staff on shift. Due to the repeat violation, licensee was made aware that a civil penalty of $1000.00 will be assessed on today's date of February 9, 2026. Appeal Rights were provided. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Feb 16, 2026

87205 Accountability of Licensee Governing Body The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility ...This requirement is not met as evidenced by: Based on LPA observation, the licensee did not ensure 2 staff are working at the facility at all times, as agreed upon during NCC meeting. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee stated she would submit an updated LIC 500, which was collected during today's visit. Licensee stated she would send LPA copies of the employee packet for the new hire, which would be the second staff on shift. LPA to receive documents by POC due date

Type of visit: Post Licensing

On January 16, 2026, Licensing Program Analyst (LPA) Arvin Villanueva arrived at the facility unannounced to conduct a post-licensing inspection and quarterly monitoring visit. LPA met with staff on duty, Mere Faletono (S1), and explained the purpose of the visit. Upon arrival, there was one staff member on duty (S1). During the visit, there were four residents in care. Later, S2 arrived to assist. According to the Personnel Report (LIC500), Administrator Tevita Kaloulasulasu (AD) was scheduled to work today from 8:00 a.m. to 3:00 p.m.; however, staff reported that AD was working at another facility. The licensee, Adi Lina Tuiloma (S2), arrived at the facility at approximately 10:45 a.m. Per conversation with Adi, there was a staff call out and she had to take a resident to their appointment. However, Adi did not ensure proper staffing as agreed during a Non-Compliance Conference on September 25, 2025. LPA conducted a physical inspection of the facility, including resident bedrooms, bathrooms, kitchen, common areas, and outdoor spaces. LPA also reviewed records for 4 of 6 residents and 4 of 8 staff members based on the LIC500 dated December 1, 2025. {Con't 809-C} The following deficiencies were observed during the visit: The licensee previously agreed during a Non-Compliance Conference on September 25, 2025, to have at least two caregivers on duty at all times. Today, only one staff member was present when LPA arrived. In the pantry, LPA observed a box of hygiene wipes stored with food items. In the kitchen refrigerator, LPA observed opened food items without labels or dates. The refrigerator did not have a thermometer, and its temperature could not be determined. The kitchen freezer temperature was 15 degrees Fahrenheit. A can of beer was found in the kitchen freezer, accessible to residents. Staff stated the beer belongs to a resident. LPA observed a couple of red ants in a kitchen drawer near the sink. The licensee stated they use insect spray to address pests. Knives were found in the dishwasher, and two meat thermometers were stored in a kitchen drawer. LPA could not confirm if an incident report for a former resident (R2) dated November 19, 2025, was submitted to the Department. LPA could not confirm if an incident report for resident (R3) dated December 22, 2025, was submitted to the Department. Resident R1 did not have a hospice care plan available for review. The licensee admitted that a hospice initiation notice for R1 was not submitted to the Department when hospice care began. The licensee admitted there is no evidence of staff training related to hospice care for R1, stated there was training but was not documented. Based on today's visit, deficiencies are being cited. Exit interview was conducted with Adi and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: Jan 23, 2026

The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Per observation, the licensee did not ensure 2 staff are working at the facility at all times, as agreed upon during NCC meeting. This poses a potential health, safetly, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Licensee agreed to submit a written plan to ensure two staff are present at the facility at all times, as agreed upon during NCC meeting. Plan should include times when there is staff call outs and emergencies. Plan to be submitted to the Department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(25) · Plan of correction due date: Jan 23, 2026

Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, LPA found hygiene wipes stored in the pantry with food items. This poses a potential health, safetly, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Corrected on site: staff removed the hygeine wipes and stored them in a different storage away from food items.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Jan 23, 2026

Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on observation, LPA observed some open food items in the kitchen refrigerator and freezer without lable and dates. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Licensee agreed to submit a written plan for proper food storage. Per licensee, she will conduct staff training. Submit plan and proof of training to the Department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(27) · Plan of correction due date: Jan 23, 2026

All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation of the kitchen area, LPA observed red ants in one of the kitchen drawer and licensee do not have pest control service at this time. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Licensee agreed to obtain a pest control service and submit contract to the Department by POC due date.

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

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. This requirement is not met as evidenced by: Based on observation, 2 kitchen knives were observed in the dishwasher and 2 meat thermometers were observed in a kitchen drawer. This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Corrected on site: staff immediately stored the sharp objects in locked drawer.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Jan 23, 2026

: A current and complete hospice care plan shall be maintained in the facility for each hospice resident. This requirement is not met as evidenced by: Per record review and interviews, hospice care plan for R1 was not available for review during this visit. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Licensee agreed to obtain a copy of R1's hospice care plan and submit plan to the Department by POC due date.

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 other facilities and the actions needed to bring Licensee 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 Licensee's history of noncompliance. Topics discussed: Administrator oversight Staffing Reporting Requirements 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: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Licensee ADI LINA TUILOMA and administrator Tevita Kaloulasulasu Interview Method: Virtual interview (MS Teams) On 9/3/2025, 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. 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 3, 2025

Type of visit: Prelicensing

On 9/2/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct the pre-licensing inspection. LPA met initially met with staff on duty (S1) and explained the purpose of the visit. The Licensee, Adilina Tuiloma, and Administrator Tevita Kaloulasulasu, were notified of the visit. The Administrator arrived at 11:15 am. The Licensee arrived at around 12:30pm. Overview: The facility is a single-story home situated in a residential neighborhood. It will be licensed to accommodate up to six elderly residents. According to the fire clearance, Bedrooms #1 through #6 are approved for non-ambulatory residents. Bedroom #7 has been designated as the staff room. The facility does not have clearance for bedridden residents, delayed egress systems, or locked exterior gates. Facility submitted hospice waiver request for 1 resident. Initial Observation: Upon arrival LPA was greeted by staff on duty (S1). Present during this visit were 5 residents in care, with one staff on duty (S1). One staff from an outside agency was also present providing care for one resident. Room temperature was at 74 degrees Fahrenheit upon arrival. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 5 of 6 resident bedrooms. LPA measured the hot water temperature in the 3 of 3 bathrooms to be between 109 and 110 degrees Fahrenheit. All resident bathrooms were observed to be in good repair at this time. Advisory was provided to install grab bars in one of the bathrooms. Advisory was provided to ensure the fire door remain close at all times. Advisory was provided to update their facility sketch to include the fire door and location of their shut off valves. {809-1} Fire extinguisher was observed in the kitchen area, and it was last inspected on 3/26/2025. Smoke and carbon monoxide detectors were observed throughout. One carbon monoxide detector was tested and found operable at this time. Three smoke detectors were tested and found operable. In the kitchen area, LPA observed at least seven day non-perishable and two day perishable food supplies. Kitchen refrigerator and freezer were maintained at regulatory temperature. Pantry is located at the resident hallway and was observed to be stocked with non-perishable food items. Medication cabinet was observed to be locked and not accessible to residents in care. Toxic materials, cleaning supplies, sharp objects and other dangerous items were observed to be in locked storage. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Emergency walkways were observed to be unobstructed. Facility has one exit gate and was observed to be in good condition at this time. Component III was conducted with the Administrator. Based on today’s inspection, this Pre-Licensing is complete and this facility has no deficiencies at this time. Exit interview was conducted and a copy of the report was provided upon exit. {809-2}the state’s words, verbatim · CDSS document, Sep 2, 2025

The state marks this report as 10 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.