LEGACY SENIOR CARE

Official classification

Type A

Official code

87463(a)(b)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident This requirement is not met as evidenced by: Based on interviews and record review the licensee did not meet the needs of resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to conduct a training for all staff concerning resident elopement. Administrator to send to LPA the date of training that will take place for the staff by 5/14/26. Once training takes place, administrator to send into CCL a copy of the training.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87461(a)(b)

Regulation authority

CCR

What the official deficiency says

87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; (2) is confused or forgetful; This requirement is not met as evidenced by: Based on interviewed and record review the licensee did not provide sufficient supervision which poses an immediate health , safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to submit a plan into CCL on how staff will supervisor and redirect residents that are an elopement risk. Plan to be submitted into CCL by 5/14/26.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, staff are not providing medications as ordered by physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator to obtain medications for R1 and R2, or receive updated medication orders from physician. Administrator to send into LPA a receipt of medications purchased or updated orders by 5/14/26.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(b)(1)(F)

Regulation authority

CCR

What the official deficiency says

Licensing Fees. (b) (1) In addition to fees set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This was not met by evidenced by: Overdue licensing fees have not been paid for the 2025 year.

Official plan of correction

Licensee will make payment in full for annual licensing fees due by POC due date of 03/19/2026.

Deadline recorded: Mar 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee is to submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training. Additionally, Licensee will reach out to R1, R2, R3 doctors for updated medication list. Due by POC due date

Deadline recorded: Oct 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). 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. This requirement is not met as evidenced by: Based on medication audit and interviews facility did not comply to the section cited above as Administrator did not ensure medications are given as prescribed, which poses a immediate health and safety risk for residents in care.

Official plan of correction

Licensee is to submit a plan on how they will ensure all Administrative duties are completed in a timely manner. By POC due date.

Deadline recorded: Oct 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on records reviewed, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.

Official plan of correction

Licensee is to have two (2) staff by 11/01/2025 and submit an updated LIC500 reflecting at least of two (2) caregivers minimum working at the facility during waking hours of 7 a.m - 7 p.m including the weekends and one (1) caregiver at night shift.

Deadline recorded: Nov 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as it has been identified the facility has one (1) staff working at the facility 24 hours a day. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee is going to make job a posting on Indeed by 08/16/2025. Additionally, reaching out to people in church and contacting family and friends. Licensee plans to hire two people.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405Administrator - Qualifications and Dutie(a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. 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. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as the Administrator is at the facility ten (10) hours a week. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will update LIC500 and have themselves on the schedule three days a week at the facility.

Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit the facility did not ensure that residents’ medications were reordered and present in the facility resulting in resident’s not being administered their prescribed medications. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee shall conduct the following: 1. Obtain updated medications orders for all resident’s in care 2. Compare medications present in the facility with resident’s medication orders 3. Order any medications prescribed to residents that are not present in the facility 4. If there are any medications in the facility that have been discontinued, the licensee shall obtain discontinue orders from physician and follow medication destruction regulations 5. Submit a plan on how the facility will ensure resident’s medications are ordered timely. Plan shall include procedures, staff responsibilities and training The licensee shall submit all resident current medication orders and discontinued orders by POC date (24 hours). The licensee shall submit plan by (2 weeks).

Deadline recorded: Aug 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) winthin 24 hours of the facility having a fire

Official plan of correction

LPA went over with Licensee the reporting timeframe. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025

Deadline recorded: Mar 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above due to caregiver not being associated with the facility which poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee will submit a statement of understanding to LPA Ratajczak that all staff must be fingerprint cleared and/or transferred prior to working in the facility. POC due 02/20/2025

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above due facility laundry room door being unlocked and open making chemicals assessable to residents in care.

Official plan of correction

Licensee is to lock laundry room door immediately. Licensee is to conduct a staff training regarding this regulation and submit a copy of who attended the training to LPA. POC due 02/20/2025

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above due to Administrator not reporting to Community Care Licensing (CCL) when the facility heater was out for two (2) days.

Official plan of correction

LPM and LPA went over with Licensee what needs to be reported. Licensee is to submit a statement of understanding of this regulation. Additionally, the licensee shall submit a plan to the department on how the licensee will ensure the facility will meet reporting requirements timely. POC due 03/05/2025

Deadline recorded: Mar 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and records, the licensee did not comply with the section cited above as it has been identified that resident’s require additional staff during waking hours.

Official plan of correction

License is to have two (2) staff on the floor during waking hours. Licensee is to hire additional staff and send LPA updated LIC500 as well as the new staff facility file. POC due by 03/05/2025

Deadline recorded: Mar 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above due two (2) out of six (6) residents files being incomplete with signatures.

Official plan of correction

Licensee is to have R1s responsible party sign admission agreement. Licensee is to obtain an updated Physician's Report/ LIC602 for R2 and ensure it is signed by physician. Once completed send a copy of both to LPA. Additionally, the licensee shall submit a plan to the department on how the the licensee will ensure resident's records are complete and maintained. POC due 03/05/2025.

Deadline recorded: Mar 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews the licensee did not comply with the section cited above as staff had left the facility and residents were left unattended.

Official plan of correction

Licensee is to conduct a training with staff regarding supervision as well as submit a LIC500 with back up staff. POC due by 02/20/2025

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 residents were residing in a room only cleared for one (1) non- ambulatory resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2024 Plan of Correction Licensee is to move one of the residents into another room and will send confirmation to LPA once completed. Additionally Licensee will submit a state of understanding of this regulation to LPA.