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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 07/19/2021
Date Signed: 07/19/2021 06:04:26 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342700597
ADMINISTRATOR:MARLENE M BREMERFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 59DATE:
07/19/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Gregory Green and Shelly Li TIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced continuation annual inspection visit on 07/19/2021 at 11:57 AM. LPA Martinez met with Gregory Green and stated the purpose of today’s visit. LPA inspected the medication room of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 160 non-ambulatory residents. There are currently fifty-nine residents who reside at this facility, which two residents are receiving hospice care.

LPA Martinez reviewed ten resident files, which were up to date. LPA Martinez reviewed nine employee files, which eight out of nine employees were missing first aid certificates. One out of nine employees was missing TB and health screening form. LPA Martinez reviewed 3 medication administration records (MAR). Resident 1, resident 2 and Resident 3's MAR's were not filled out on the various dates: July 6th, 16th and 17th. Furthermore, resident 2 is missing the following prescribed medication: Lisinopril 5M Tab and Glutose 15 3's. The facility first aid kit is up to date.

The following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted and 809, 809D, and appeals right given to Gregory Green at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342700597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87411 (c)(1)Personnel Requirements -General (All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter...(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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This requirement is not met as evidenced by. Based on interviews and records review, the administrator did not ensure 8 out 9 care staff had a copy of their first aid certificate in their employee file. This posed a potential risk to residents in care.
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Type B
07/26/2021
Section Cited

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87411 (f)Personnel Requirements -All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...This requirement is not met as evidenced by. Based on interviews and records review
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One out of nine employees was missing TB and health screening form. (staff 2). This posed a potential risk to residents 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342700597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2021
Section Cited

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87465(a)(5)Incidental Medical and Dental Care: 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:
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This requirement was not met as evidence by: Based on record review, the licensee did not ensure R2 had a supply of Lisinopril and Glutose in the facility. This poses an immediate health and a safety risk to residents in care.
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Type B
07/26/2021
Section Cited

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87465(6) Incidental Medical and Dental Care:6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...This requirement was not met as evidence by:
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Based on record review, the licensee did not ensure to maintain a record of centrally stored prescription medications for R1. Medication Administration Record was not filled out on the 07/16/21 and 07/17/21. This posed a potential health and a safety risk to residents 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3