342700597-9-7-2021-27-AS-KHOS-C6NJGE-20210908070209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 09/07/2021
Date Signed: 09/07/2021 01:27:56 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
07/13/2021 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20210713174009

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	MARLENE M BREMER		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 58	DATE:	09/07/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tanysha Borromeo		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident's are locked out of their rooms.
Facility not dispensing medication in a timely manner.
Staff yelled at resident's.

INVESTIGATION FINDINGS:

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On 09/01/2021 at 11:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Tanysha Borromeo and explained the purpose of today's visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility records, and toured the facility. LPA Martinez reviewed resident 1's (R1) Medication Administration Record (MAR), and it was learned Alprozolam 0.5MG is a PRN (take 1 1/2 tablet by mouth 3 times a day as needed). It was also learned that R1 was administered Alprazolam 0.5MG on 07/12/2021 at 7:30 pm and on 07/13/2021 at 5am, 12pm, and 7:30pm. It was also notated that R1 was adminstered 0.5MG Alprazolam on 07/14/2021 at 6am, 12pm, and 7pm.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20210713174009

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: 09/07/2021

NARRATIVE

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LPA Martinez interviewed R1, and R1 reported Alprozolam 0.5MG should be administered at 6am, 12pm, 6pm. However, the medication order does not specify the time the medication needs to be administered and does not provide wait periods between doses. In addition, facility PRN documentation indicated when R1 requested Alprozolam 0.5MG, and the documentation reviewed did not indicate that Alprozolam was not administer in a timely manner.

Moreover resident apartment entry doors have locks, and the doors lock from the outside. All residents have a personal key to unlock their apartment entry door. In addition, facility staff are able to unlock a resident's apartment door if a resident forget their key in their bedroom, or if a resident looses their key. Additionally, the facility has an emergency and disaster plan. The plan includes designating an employee to conduct a resident roll call, and this person is responsible for the supervision of residents during an evacuation or relocation. Furthermore, residents will be given wrist bands and staff will have a resident roster list to ensure all residents are accounted for. Staff will also tag each apartment door against the doorframe with bright masking tape, which this indicates there is no resident inside the apartment.

LPA Martinez interviewed R1, and R1 reported never witnessing a facility staff yell at a resident. LPA Martinez interviewed R2, and R2 reported being satisfied with the care being provided at this facility. R2 reported being satisfied with the administration of medications. LPA Martinez interviewed R3, and R3 stated having no concerns with the staff and is satisfied with the care being provided at this facility. R3 also reported having a room key and not having any issues with getting into her room. Resident 4 (R4) reported having a room key and having no issues or concerns. R4 also has a call button pendent necklace. During the interview, the call button pendent was pressed, and a caregiver arrived at R4's bedroom within 3 minuets.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. Exit interview conducted and a copy of the report was provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
07/13/2021 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210713174009

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	MARLENE M BREMER		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 58	DATE:	09/07/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tanysha Borromeo		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is not taking necessary precautions to prevent the spread of COVID-19.
Facility is hazardous

INVESTIGATION FINDINGS:

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On 09/07/2021 at 1:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Tanysha Borromeo and explained the purpose of today's visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility records, and toured the facility. On 07/23/2021, the Department conducted a virtural visit to discuss the Covid-19 Mitigation plan and the lack of implementing Covid-19 precautionary measures. Other covid-19 concerns disscussed were: staff not wearing PPE, Facility not screeing visitors, reporting covid-19 positive cases to the Department, and disinfecting/cleaning.

Futhermore, on 07/28/2021 a virtual confrence was conducted. The virtural confrence was conducted to review concerns in regards to: PPE fit testing for staff, improper donning and doffing of PPE, Lack of signage for masking and social distancing, and Lack of signage at entrance alerting active Covid positive cases.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20210713174009

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: 09/07/2021

NARRATIVE

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On 08/11/2021, the Department conducted a virtual Covid-19 case management visit. During the case management visit, the order of cleaning, cleaning supplies, and infection control was discussed. As a result of previous conducted conferences, case management, and technical assistance (TA) virtual visits, the facility has been cited for not taking the necessary precautions to prevent the spread of COVID-19. The facility have been given plans of corrections, and the facility has begun initiating Covid-19 precautionary measures.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies have been cited on the 809D pages on the following dates, 07/16/2021 and 07/23/2021, and plan of corrections were given on these dates. The facility has implemented Covid-19 precautionary measures, and have submitted their plans of corrections to the Department. An exit interview was conducted and a copy of the is report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4