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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701616
Report Date: 09/21/2026
Date Signed: 09/21/2026 02:14:15 PM

Document Has Been Signed on 09/21/2026 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGACY SENIOR CARE IIIFACILITY NUMBER:
342701616
ADMINISTRATOR/
DIRECTOR:		KALOULASULASU, TEVITAFACILITY TYPE:
740
ADDRESS:9279 Orange Crest CTTELEPHONE:
(916) 701-7737
CITY:Elk GroveSTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sera NakalevuTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required visit. LPA Valerio met with facility staff, Mere Falentono, and explained the purpose of the visit. Facility staff notified the facility group chat via text and informed LPA that administrator Sera will meet LPA Valerio. LPA received a phone call from Administrator Sera Nakalevu stating she will come to the facility shortly. LPA Valerio was met by Licensee Adi Lina Tuiloma, Administrator Sera Nakalevu, and prospective administrator Jacquilyn Parratt.

LPA Valerio observed residents in lounging in the milieu watching television, talking to one another, and conducting a tele-health visit. Facility staff served lunch, which was pizza hot pockets, burritos, orange slices, and choice of drink. LPA Valerio and facility staff toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed the common areas, such as the two (2) living rooms, the kitchen area, and the dinning area. They were observed to be fully furnished, organized and clean. Furniture was observed to be in good repair and without stains or rips. LPA Valerio observed the kitchen tiles to have a crack in seven of the tiles. It did not appear to be a tripping hazard at this time; however, a technical violation was issued for licensee to fix before it becomes hazardous. Resident bedrooms were observed to be clean, free from odors, and appeared to have fresh linens on the beds. The rooms were observed to have a bed, night stand, lamp, and closet/dresser space. Emergency exit ways were free from obstructions. The facility was observed to have a fire extinguisher, which was last inspected on July of 2026. LPA Valerio observed carbon monoxide detectors and a fire detector. LPA Valerio observed the resident bathrooms to be clean and fully stocked with hygiene supplies. The hot water temperature was measured to deliver water at 109.6 degrees Fahrenheit. The facility thermostat was set to 74 degree F.

Continues on LIC 809 - C...
Stephen Richardson
Christina Valerio
DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616
VISIT DATE: 09/21/2026
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LPA Valerio observed the facility food supply. LPA Valerio observed the pantry to have a 7-day supply of canned foods located at the top of the pantry. LPA Valerio observed the facility to have a two day supply of perishable food items. However, LPA Valerio informed Licensee and Administrators that it did appear that additional snacks could be purchased. At the time of the visit, LPA Valerio observed resident's personal bought items. The only snack available was cookies. However, staff did indicate that many of the snacks are cooked fresh from the staff. Administrators informed LPA that the facility has a weekly food budget of $250.00 per week. According to the USDA Official Food Plans, the typical baseline for a single older adult is $6.50 to $7.50 per day per resident, which is the cheapest food plan. At $250.00 per week, the estimate of food cost per resident at this facility is $5.95, which may be considered too low. A technical violation was issued and discussed with Administrators and Licensee.

LPA Valerio observed an emergency supply of water. LPA Valerio observed the backyard to be free from obstructions. LPA Valerio observed the facility to have an area for outdoor sitting and activities. LPA Valerio observed staff to resident interactions to be very positive. Residents were observed laughing, requesting for assistance, and engaging with one another. LPA Valerio observed the facility to have medications, sharps, and any hazardous items to be locked and inaccessible to residents in care.

LPA Valerio observed resident and staff files. Resident and staff files were complete with required documents.

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, 08/03/2026, and 09/21/2026. 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 08/04/2026 through 09/21/2026, totaling to the amount of $4,900.00. Failure to correct may result in the continued daily assessment of civil penalties.

According to the LIC 500 dated September 1, 2026, the second staff member that should have been on shift was Staff (2) and was scheduled to be at the facility from 7:00 AM to 7:00 PM. LPA Valerio did not observe staff 2 at the facility. According to an interview with Licensee Adi Lina Tuiloma,
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY SENIOR CARE III
FACILITY NUMBER: 342701616
VISIT DATE: 09/21/2026
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According to the LIC 500 dated September 1, 2026, Staff 1 is the primary caregiver and have Saturday and Sunday off. According the Medication Administration Records, LPA Valerio observed S1 signing off every day from September 1, 2026 until September 18, 2026. If these records are true and accurate, S1 worked 18 days straight.

LPA Valerio requested the following be sent to christina.valerio@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of your liability insurance.

Per California Code of Regulations (CCR) - Title 22, Technical Violations and civil penalties were issued during today's visit. Failure to correct deficiencies may result in additional civil penalties. An exit interview was held with Licensee Adi Lina, and a copy of this report was left.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Christina Valerio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026
LIC809 (FAS) - (06/04)
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