342700597-7-26-2021-27-AS-KHOS-C5BS9M-20210727134057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:37:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210507144609

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	VICKIE KAISER		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 59	DATE:	07/26/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Gregory Greene, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Questionable death
Timely medical care not sought for resident

INVESTIGATION FINDINGS:

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On 7/26/2021, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the investigation findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with administrator Gregory Greene.

The investigation was conducted by the Department which consisted of reviews of the medical records and interviews with facility management and staff. The complaint alleges that staff’s failure to seek timely medical attention which cause the death of resident (R1). The complaint also alleges that facility staff failed to seek timely medical attention when resident (R1) air supply ran out due to a power outage at the facility.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210507144609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/26/2021

NARRATIVE

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Throughout the course of the investigation, the Department conducted interviews and reviewed medical records. The investigation revealed that resident’s (R1) primary diagnosis was unspecified pulmonary fibrosis. According to Hospice medical records, hospice staff certified that R1 was “terminally ill” with a life expectancy of six months or less. R1 was tested positive for COVID-19 on 1/21/21. R1 was oxygen dependent. Staff (S1) stated that she was present during the power outage and observed that R1 was on oxygen constantly throughout the night. Staff (S2) confirmed that R1 was never out of oxygen prior to 911 arriving on 1/27/21. Staff S1 and S2, who were present during the call to 911 for R1 stated that at no point R1 ran out of oxygen or was unable to receive his portable oxygen.

This Department has investigated the allegations noted above and have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or was without a reasonable basis.

Exit interview was conducted with Administrator Gregory Green and a copy of the report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
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

LIC9099 (FAS) - (06/04)

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