Legacy Senior Living 2

Type of visit: Required - 1 Year

On August 14, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Thi Nhu Mai Do was present and assisted with today's inspection. LPAs observed that Thi Nhu Mai Do has a valid Administrator certificate which expires on October 17, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six residents, of which five can be non-ambulatory residents and of which one may be bedridden. The facility has an approved hospice waiver for six residents. The facility is a two home. The first floor consist of four resident bedrooms, two of which are shared, two shared resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. The second story is for staff use only and consist of two staff bedrooms and two staff bathrooms. LPAs, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, LPAs observed five residents in care and two care giving staff present. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the four resident bedrooms and observed them to be clear of any hazards. LPAs observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean linens and blankets. LPAs observed additional linens to be stored in a closet. LPAs inspected the two shared resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floors mats. Faucets and toilets were operational. Hot water temperature measured between 112.1 and 113.1 degrees Fahrenheit. CONTINUED ON LIC809-C LPAs observed the facility has a two day perishable and a seven day non-perishable food supply in the kitchen. LPAs observed kitchen appliances to be clean and operational. LPAs observed unsecured insulin injection pens to be stored in the kitchen refrigerator where it can be accessible to residents in care. LPAs observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPAs observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPAs observed a fire extinguisher to be mounted on the wall in the kitchen and it was observed to be charged. LPAs tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPAs observed the facility conducted their most recent emergency disaster drill on July 1, 2026. LPAs observed the centrally stored medication to be kept in a locked cabinet near the kitchen. LPAs observed a first aid kit to be stored in the same cabinet which had all the required components. LPAs observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPAs observed the garage to be used for storage and laundry. LPAs observed the facility has a three day emergency food and water supply to be stored in the garage. LPAs observed all other common areas to be free of any hazards or obstructions. LPAs, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPAs observed the exterior to be clear of any obstructions or hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. LPAs observed the perimeter gates of the facility to be self-latching and can be opened in an evacuation. There are no bodies of water on the premises. LPAs reviewed all five resident files. All the required documentation were present and current in the resident files reviewed. LPAs reviewed the residents' medication and medication administration records. LPAs reviewed three staff files. LPAs observed that the facility did not have Health Screenings or TB tests on file for Staff #1 (S1) or Staff #2 (S2). LPAs observed that zero out of the three staff present during the visit had a CPR training card. LPAs also observed that S1 did not have a criminal record clearance. Per a review of Guardian, S1 is currently "In Process". Per the staff file review, S1 started their employment with the facility on August 1, 2026. Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. A civil penalty will also be issued in the amount of $500.00 for caregiver background check. An exit interview was conducted with Administrator Thi Nhu Mai Do. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Aug 14, 2026

Allegation investigated: Resident was issued an unlawful eviction. Facility did not meet reporting requirements.

On August 12, 2026 at 10:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver findings at the above facility for the above allegations. LPA Kim met with Administrator (ADMIN) Thi Nhu Mai Do and explained the purpose of the visit. During the investigation, LPA Kim conducted a physical plant tour inside and outside of the facility with ADMIN Do. LPA Kim reviewed R1’s records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans, and other pertinent records. LPA obtained resident roster, staff roster, and other pertinent records. LPA Kim conducted interviews with one (1) witness interview and two (2) staff interviews. The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Resident was issued an unlawful eviction It is alleged that the facility issued an unlawful eviction notice. Based on record review, the Admission Agreement stated that the facility can evict a resident for the Inability of the licensee to meet the resident's needs after admission. The Admission Agreement stated based upon a reassessment of the resident's needs conducted pursuant to applicable regulations, the licensee/administrator of the facility and the person who performs the assessment may determine that the facility is not appropriate for the resident. An email sent from Administrator Do to R1's Responsible Party dated October 12, 2025, giving a 30 day notice to leave the premises for the increase in the need for care and domestic disturbances. The facility did not notify CCLD about the 30-day notice in writing within five days. Also, the email does not meet the requirement as an eviction notice because after admission the facility did not conduct a reappraisal to indicate a new or updated care plan was made. As of August 12, 2026, there was no new reappraisal and the facility only has Appraisal Needs and Services Plan dated March 3, 2025, which lists R1’s needs with arthritis from the hip and knee, anxiety concerns, no concerns with continence needs, no special medication, and additional services are needed. R1’s Physician’s Report dated February 21, 2025, primary diagnosis is on hypertension, depression, dementia, and there are concerns with their mental condition in regard to confusion. Based on interviews conducted two out of three staff denied the allegation. One out of three staff could not confirm or deny the allegation. S1 and S2 stated that R1 was evicted from the facility due to increased confusion and domestic disturbances. S1 stated that a new reappraisal was not assessed prior to R1 leaving the facility. S1 stated they did not follow the eviction procedures as stated in the admission agreement for resident who needed a higher need of care prior to leaving the facility. Based on the information gathered, there is sufficient evidence to corroborate the above allegation. The facility did not follow admission agreement eviction procedures to reassess R1 to determine if R1 was not appropriate for the facility. S1 stated they did not notify Licensing about the eviction or conduct a reassessment prior to R1 leaving the facility Continued on LIC9099C Allegation: Facility did not meet reporting requirements It is alleged, the facility is also not reporting incidents regarding the presence of police at the facility. Based on record review, Police Report P25041740 dated May 9, 2025, R1’s visitor attempted to remove R1 from the facility. Police Report P25044209 dated May 16, 2025, at 10:42 AM, where R1’s visitor attempted to visit R1. R1 clearly stated that they did want the visitor there and doesn’t want the visitor at the location. Visitor refused to leave the premises. On October 21, 2025, LPA Kim reviewed the Serious Incident Report Log Portal and did not observe any incidents reported by the facility for May 9, 2025, and May 16, 2025. The portal indicated no incidents from the facility. On October 22, 2025, LPA Kim received incident reports from the facility that indicated that they were faxed written on the LIC624. As of August 12, 2026, LPA Kim did not observe any of the LIC624 on record that were provided through email. The facility could not provide proof that faxes were sent on the dates indicated on the LIC624. Based on interviews conducted, two out of three staff denied the allegation. One out of three staff could not confirm or deny the allegation. S2 stated that S3 sent out the serious incident reports through fax to the California Department of Social Services (CDSS) Orange County Regional Office. S1 stated that S3 would mark on the LIC624 the dates the Incident Reports were sent through fax. S1 stated that they trusted and believed that S2 sent the incident reports through fax, but never checked to follow through on it. Based on the information gathered, there is sufficient evidence to corroborate the above allegation. The facility had filled out incident reports, and wrote on the reports they faxed in the reports, but there is no proof that they were sent through fax and/or email. Based on information gathered through observation, the preponderance of evidence standard has been met, therefore, the allegations Resident was issued an unlawful eviction and Facility did not meet reporting requirements. were found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An exit interview was conducted, and a copy of this report, and the appeal rights were provided to Administrator Thi Nhu Mai Do.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 22-AS-20251016083056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224 · Plan of correction due date: Aug 26, 2026

87224 (a)The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required ... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted... and the licensee.., who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met evidenced by: Based on record review and interviews, Licensee unlawfully evicted R1 from the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Licensee stated they will send proof that they read, understood, and sign an acknowledgement of CCR 87224 regulation and create a sample eviction letter to CCLD via email to edward.kim@dss.ca.gov by POC due date August 26, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 26, 2026

87211(a)(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... This requirement was not met evidenced by: Based on record review, interviews, and observation, Licensee did not send incident reports for May 9, 2025, and May 16, 2025, of Incidents involving R1, R1's Family, and the facility to OCRO through fax or email. This poses a potential health, safety, or personal rights risk to person in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Licensee stated they will send proof they have read CCR 87211, understood, and sign an acknowledgement of CCR 87211 and send all future incident reports to the CDSS OCRO through fax or email to CCLD via email to edward.kim@dss.ca.gov by POC due date August 26, 2026.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management visit to document a deficiency observed during the investigation of complaint 22-AS-20251016083056 but unrelated to the allegations investigated. During a tour of the physical plant, LPA observed and reviewed the record of S1 who was working in the facility without having background clearance and association with the facility. A deficiency was cited per Title 22 Division 8 Chapter 6 for S1 not having background clearance and association with the facility. A Civil Penalty was assessed. An exit interview was conducted and a copy of this report, LIC421BG, LIC811, and appeal rights were provided to Caregiver Pepito Vitug.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 22, 2025

87355(e)(2) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met evidenced by: Based on record review, Licensee failed to ensure S1 has a criminal background clearance. This poses an immediate health and safety risk to residents in care. Civil Penalty assessed during the visit.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee stated they will send a statement of Acknowledgement and signature of CCR 87355(e) to CCLD via email to edward.kim@dss.ca.gov by POC due date October 22, 2025.

Type of visit: Required - 1 Year

On August 7, 2025, at 2:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Caregiver Emma Tablang. A phone call was made to Assistant Administrator (ASAD) Catherine Hsi who explained Administrator Thi Nhu Mai Do was not available because they will be away from the facility from August 4, 2025, to August 20, 2025. ASAD Hsi stated they could not attend today’s visit and CG Tablang could sign on behalf of the facility. The facility is licensed to operate for five (5) non-ambulatory residents, of which one may be bedridden and have a hospice waiver for six (6) residents. The facility is a two-story building located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two bedrooms on the second floor, four (4) bathrooms, living room, common area, dining area, office area, kitchen, attached 2-car garage, and an outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with CG Tablang. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be clean and operational. Bathroom water temperature measured between 132.0 degrees F and 132.9 degrees F. A comfortable temperature of 78 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. LPA observed the front left burner was not in working order. Emergency food, water, and supplies are stored in the kitchen pantry and in the garage. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drills quarterly and was last conducted on May 12, 2025. A working telephone (714-594-3270) remains available. Smoke detectors and carbon monoxide detectors were operable. The fire extinguisher was mounted in the kitchen. LPA Kim conducted an audit of four (4) residents (R1-R4) files, and 2 (2) staff (S1-S2) personnel files, and medication and medication administration records. LPA observed S1 and S2 did not have any training hours for 2025. LPA conducted interviews for two (2) residents and two (2) staff. Based on today’s visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed the water temperature for bathroom 1 measured at 132.0 degrees F and bathroom 2 measured at 132.9 degrees F. LPA observed front left burner on the stove did not light unassisted. LPA observed S1 and S2 did not have any 2025 training hours completed. An exit interview was conducted and a copy of this report, LIC811, and appeal rights were provided to Caregiver Emma Tablang.the state’s words, verbatim · CDSS document, Aug 7, 2025

Allegation investigated: Staff restricted resident’s ability to have visitors Staff did not safeguard resident's personal belongings

On May 23, 2025, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegation. LPA Kim met with Licensee Thi Nhu Mai Do and explained the purpose of the visit. During today's visit, LPA Kim conducted a physical plant tour inside and outside of the facility with Licensee Do, and no concerns were observed. LPA Kim reviewed R1’s records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans, and other pertinent records. LPA obtained resident roster, staff roster, visitor’s log, and other pertinent records. LPA Kim conducted one (1) resident interview, one (1) witness interview, and two (2) staff interviews. Continued on LIC9099C Unsubstantiated Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation Staff restricted resident’s ability to have visitors and Staff did not safeguard resident's personal belongings. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted a copy of the report was provided to Licensee Thi Nhu Mai Do. The investigation revealed the following: Allegation: Staff restricted resident’s ability to have visitors During LPA’s interview with the R1 around 9:20 AM, LPA observed resident (R1) kept repeating themselves and having short memory of the conversation. Later in the day around at 11:30 AM, R1 asked LPA if they were going to interview them. R1 did not recall speaking with LPA earlier that day. Based on record review, according to physician’s report dated February 21, 2025, R1 is confused and disoriented. R1 has a designated POA per review of resident’s Admission Agreement dated March 3,2025 POA instructed the facility through email dated May 12, 2025, not to permit a family member to visit and take resident off the facility for safety reason. Based on interviews conducted, one resident, two staff, and one witness denied all allegations. Witness #1 (W1) stated on May 16, 2025, Police came to the facility to instruct the family member not to see R1 in the facility and administrator was also informed. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff did not safeguard resident's personal belongings. It is alleged resident’s planner was missing. Based on interviews conducted, one resident, two staff, and one witness denied this allegation. Witness (W1) stated the POA informed that R1 has two planners and instructed them to take one from R1 to prevent confusion of their daily activities. Staff#1 stated POA instructed the facility to take one planner from R1 in the morning and keep it somewhere safe in the facility and return the planner the next day. During the visit, LPA observed R1 has their two planners with them while sitting at the dining room. LPA confirmed with R1 that those were R1’s planners and they were not missing. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. Continued on LIC9099Cthe state’s words, verbatim · CDSS document, May 23, 2025 · control 22-AS-20250519120454

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management visit to document a deficiency observed during the investigation of complaint 22-AS-20250519120454 but unrelated to the allegations investigated. During a tour of the physical plant, LPA observed the facility did not notify the Regional Office about the change of administrator. A deficiency was cited per Title 22 Division 8 Chapter 6. The facility did not notify Regional office about the change of administrator. An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Thi Nhu Mai Do.the state’s words, verbatim · CDSS document, May 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(k) · Plan of correction due date: Jun 6, 2025

87407(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days... This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above. This poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Licensee states they will send completed POC with the following documents Administrator Certificate LIC 200, LIC 308, LIC 500, LIC 501, LIC 503, LIC 9182, and a copy of ID Card to CCLD via email to edward.kim@dss.ca.gov by POC due date June 6, 2025.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to the facility to conduct a Pre-Licensing inspection. LPA identified herself and discussed the purpose of the visit with Applicant Thi Nhu Mai Do. Consultant Ban Nguyen was present as well. An initial application to operate a Residential Care Facility for the Elderly was submitted to Community Care Licensing on 04/18/2024 for a capacity of four non-Ambulatory, one Ambulatory, and one bedridden resident. Upon entry, facility appears clean, safe and sanitary. Facility has all required postings at entrance. LPA Martinez along with Applicant Do and Ban toured the facility and observed the following: Structure: Facility is a two story, 6 bedroom, 4 bathroom house with an attached garage. The outside exit gates are closed and unlocked. Garage: Two car garage with a small built room with washer/dryer; will be used as laundry room and storage only. Living Room/Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be two private and two shared. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Staff: Facility will have live-in staff and will occupy upstairs bedrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply. Bathrooms: All resident bathrooms have a working toilet/wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Applicant understands to have a supply of 2 day perishables as well as 7 day non-perishables at all times when residents present. Smoke Detectors: Smoke detectors are hard wired; carbon monoxide detectors were operational. Fire extinguisher is fully charged and mounted. The three non-Ambulatory bedrooms have self closing Fire doors. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. (cont on LIC809C) Toxins/Sharps: Facility has secured areas for toxins and sharps. Water Temperature: Hot water temperature is within regulatory requirements. Emergency Supplies: LPA observed ample emergency water as well as a posted Emergency Disaster Plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer. LPA observed a First Aid Manual. There is are locked kitchen cabinet for medication. Facility to use a medication administration record. Resident & Staff File: Records are to be stored and secured. Reading Material, Games, and Equipment: LPA observed a board games for residents use. Backyard: LPA observed a clean backyard with ample shaded seating for residents and visitors. Fire Clearance: Approved for four non-Ambulatory and one bedridden resident on 05/08/2024. Component III was completed with Applicant during today’s inspection. Applicant will obtain liability insurance once the application is approved. Facility appears to be in compliance and ready to be licensed. License will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to the email on filethe state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: TRAN, HONGLAN and Do, Thinhumai - Administrator/Licensee Interview Method: Telephone interview On 08/01/2024, 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. 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, Aug 1, 2024