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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 07/23/2021
Date Signed: 07/23/2021 05:43:23 PM

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:
07/23/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gregory Green TIME COMPLETED:
05:30 PM
NARRATIVE
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Regional Manager Krystall Moore, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Avelina Martinez, and DSS Nurse Cristina Wong contacted the facility via virtual visit to conduct a TA Covid-19 Case Management on 07/23/2021. Community Care Licensing Staff identified themselves and discussed the purpose of the virtual visit and the elements of the Covid-19 Case Management visit with Gregory Green, Tanysha Borromeo, Stephen Ratliff, and Melissa Orello.

The purpose of today's virtual visit is in response to reporting positive Covid-19 cases in a timely manner and to conduct a virtual Covid-19 technical assistance visit, which included a virtual tour of the facility.

The facility's first known positive case was on 07/17/2021. Community Care Licensing Department (CCLD) was not given an Unusual Incident/Injury report until 07/23/2021. In addition, the facility did not follow their Covid-19 Mitigation Plan Report. Per the facility's mitigation plan, the Infection Control Nurse and or Lead will provide a Covid-19 line list to CCLD. As of 07/23/2021, CCLD has not been given a positive Covid-19 line list.

Requested Items and Documents:

  • Positive Covid-19 Line List
  • Mitigation Plan LIC 808
  • Infection Control- PPE Education Training Agenda and Training Materials
  • Daily Staffing Schedule
  • Resident/Employee Vaccination Roster
  • Employee Employment Tracing List
  • Garbage Cans with Lids
  • Follow Up with Public Health-Infection Control Directives
  • Cross Report to Ombudsman for each Case
Continue...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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 4
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: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited

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87211 (2) Reporting Requirements 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.
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This requirement was not met as evidence by: Based on record review the licensee did not report Covid-19 positive cases in a timely manner. This posed a potential health & safety and personal rights risk to residents in care.
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Type B
07/30/2021
Section Cited

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87405 Administrator - Qualifications and Duties (d)(2)...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...Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement was not met as evidence by: Based on record review and interviews, the licensee did not ensure all applicable regulations were being implemented and did not ensure to conform and implement Covid-19 regulations. This posed a potential health & safety and personal rights 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: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2021
Section Cited

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§1569.50 (3) Denial, suspension or revocation of license; grounds; application of remedies; temporary suspension pending hearing; exclusion from licensure without right to petition for reinstatement. Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

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This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above, such as, not following Covid-19 mitigation, which the facility did not have covid-19 postings at positive resident room and staff were not wearing mask which poses an immediate health, safety or personal rights risk to persons 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: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
VISIT DATE: 07/23/2021
NARRATIVE
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In addition, §1569.50 (3): was previously cited on 07/15/2021, therefore, a civil penalty shall be assessed for a repeat violation within a 12- month period during this visit.

As a result, the following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. As exit interview was conducted and 809 report, 809D report, and appeal rights was emailed to Gregory Green due to Covid-19 pre-cautionary measures.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4