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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 07/28/2021
Date Signed: 07/28/2021 04:57:20 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:
07/28/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Gregory GreeneTIME COMPLETED:
12:00 PM
NARRATIVE
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On July 28, 2021 A non-compliance conference was conducted today virtually, via Microsoft Teams. The purpose of the non-compliance conference meeting was to discuss the inability to remain in substantial compliance with the regulations and with regards to Covid-19. Present in the meeting were Regional Manager Krystall Moore, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Chris Hopkins, Licensing Program Analyst Avelina Martinez. Facility representatives include; Licensee representatives include Jim Biggs CEO of Westbay Senior Living LLC , Gregory Greene Executive Director, Tanysha Borromeo Business Office Manager, Marlene Bremer Sales Director, Shelley Li Regional Director of Operations, Stephen Ratliff Regional Development for Westbay Senior Living LLC, Melissa Orella Administrator for sister facility in Lodi, Josh Johnson Chief Operating Officer of Westbay Senior Living LLC, Joel Goldman Legal counsel of Westbay Senior Living LLC, Stefan Oh Executive VP of Acquistions of American Healthcare Investments, and Scott Marshall VP of American Healthcare Investments. The non-compliance conference process and the Administrative Process was explained during the meeting.

The facility has been cited 21 times in the last three months. The facility was cited for the following issues, regarding Covid-19 reporting requirements, compliance regarding Covid-19, compliance with Title 22 and change of Ownership notice reporting. The facility was cited for 7 Type A citations, and 14 Type B citations.

Report continued on LIC809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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
VISIT DATE: 07/28/2021
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Issues discussed during the meeting were:
· Compliance with Covid-19 Procedures
· Staff not wearing masks
· Improper Donning and Doffing of PPE
· Facility not reporting positive Covid-19 results
· Proper use of PPE
· Inaccurate Mitigation Plan
· Lack of signage for masking and social distancing
· Lack of signage at entrance alerting active Covid
· No isolation sign posted on positive resident’s door
· No hand sanitizer and isolation wipes noted on isolation cart
· No fit testing for N95 masks
· Compliance with Title 22 Regulations
· Change of ownership
· Licensee Abandonment

The facility has stated they will do the following to achieve continued and substantial compliance:

· Follow Title 22 guidelines


· Update the Mitigation Plan and send to RO by COB 7/29/2021
  • Update a daily line list (including all residents/symptoms and staff) by 9am

    • · Set up FIT testing for necessary personnel
    · Review PIN’s sent by CDSS CCL
    · Ongoing training in all areas ( infection control, medication distrubtion,
    · Monthly QA’s on medications starting in August (available upon request)
    · Ensure Staff are Criminally record cleared and associations are updated in Guardian
    · Revise Admission Agreement to include ALWP and SSI
    · Weekly water temperature checks and document on logs (available upon request)
    · Monthly contract with Terminix will continue
    · Maintenance checks on refrigerators
    · Installation of EMR- Elder Mark
    · Contracted with 3 staffing agencies (Bright Star, Carelinks, Vitaworks)
    SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
    LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 07/13/2021
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 07/28/2021
    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
    VISIT DATE: 07/28/2021
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    • Ensure residents are receiving timely medical care.
    • Will conduct weekly testing of unvaccinated staff
    • Send over a copy of the LLC Agreement and Operating Agreement by August 6, 2021
    • Hire a nurse working 40 hours a week
    • Report COVID cases immediately via an Incident Report to the Department, Ombudsman, ALWP and LHD

    CCL will do:
    CCL will increase monitoring.
    CCL will refer the facility to Technical Support Program (TSP)

    Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Gregory Greene via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
    SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
    LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 07/28/2021
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 07/28/2021
    LIC809 (FAS) - (06/04)
    Page: 3 of 3