LEGACY SENIOR CARE II

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

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

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Nov 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 10, 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: 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,

Official 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.

Deadline recorded: Sep 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

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: 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.

Official 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.

Deadline recorded: Sep 2, 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

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.

Official 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.

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

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

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

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above as two out of five residents did not have tuberculosis testing documented on LIC602 which poses a potential risk for residents in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Licensee is to conduct an audit of residents medical assessment to confirm tuberculosis testings are conducted. Licensee is to schedule residents an appointment for tuberculosis testing if missing on file. Licensee is to inform LPA once the following are completed by May 9, 2025.