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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006554
Report Date: 08/12/2026
Date Signed: 08/12/2026 03:45:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20251016083056
FACILITY NAME:LEGACY SENIOR LIVING 2FACILITY NUMBER:
306006554
ADMINISTRATOR:DO, THI NHU MAIFACILITY TYPE:
740
ADDRESS:19142 STINGRAY LANETELEPHONE:
(714) 249-0176
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 5DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator-Thi Nhu Mai DoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident was issued an unlawful eviction.
Facility did not meet reporting requirements.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20251016083056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LEGACY SENIOR LIVING 2
FACILITY NUMBER: 306006554
VISIT DATE: 08/12/2026
NARRATIVE
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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
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20251016083056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LEGACY SENIOR LIVING 2
FACILITY NUMBER: 306006554
VISIT DATE: 08/12/2026
NARRATIVE
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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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20251016083056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LEGACY SENIOR LIVING 2
FACILITY NUMBER: 306006554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2026
Section Cited
CCR
87224
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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
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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.
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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.
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Type B
08/26/2026
Section Cited
CCR
87211(a)(1)
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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:
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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.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
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