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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 08/11/2021
Date Signed: 08/11/2021 03:21:15 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:
08/11/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gregory Green, Tanysha Borromeo, and Marlene Bremer TIME COMPLETED:
03:00 PM
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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 Microsoft Teams to conduct a virtual case management on 08/11/2021. Community Care Licensing staff identified themselves and discussed the purpose of the virtual visit and the elements of the case management visit with Gregory Green, Tanysha Borromeo, and Marlene Bremer. This visit also included Healthcare Associated Infection Department (HAI) Zenith Khwaja.

Community Care Licensing Department staff virtually toured the facility with Healthcare Associated Infection (HAI) -Zenith Quasha and facility staff Tanysha Borromeo, Gregory Green, and Marlene Bremer on 08/11/2021 at 2:00 PM. During the tour of the facility, the following facility areas were inspected: resident bedrooms; resident bathrooms, laundry room, and common facility hall ways.

Furthermore, throughout the virtual visit, the following topics were discussed:

    • Order of cleaning
    • Cleaning supplies
    • Donning and Doffing of PPE
    • Cohorting and creating a Covid-19 positive wing
    • Staffing and the use of staffing agencies
    • Dining procedures and room meal services
    • Covid-19 visitation and Activity policies
    • Infection Control

Per California Code of Regulations (CCRs) - Title 22, there were no deficiencies cited during this visit. An exit interview was conducted with Tanysha Borromeo 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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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