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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 10/06/2021
Date Signed: 10/06/2021 05:39:05 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:LORI KNOLLFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 54DATE:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lori KnollsTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/06/2021. LPA met with Lori Knolls and explained the purpose of the visit.

The purpose of the case management visit is to follow up on learned deficiencies during a complaint investigation.

It was learned the facility Executive Director and facility staff resides in a designated resident room 4 times a week. In addition, the facility is not in good repair. During today's visit, LPA Martinez observed a medical glove on the ground, broken down fountain, and overgrown shrubs/grass/trees at the residents' outside courtyard. In addition, room 57 exit door is being covered by an overgrown shrub, which is creating exit hazard. Also, the bathroom sink in room 57 has a water faucet leak. Moreover, LPA Martinez observed a dead cockroach in room 43. Additionally, there was dust build up and dead bugs under the resident's bed.

As a result, the facility is not adhering to Title 22 Regulations, and the deficiencies can be found on the 809-D report. An exit interview was conducted with Lori Knolls, and a copy of this report was given to the facility at the end of this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 2
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: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2021
Section Cited

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87303 Maintenance and OperationThe facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:
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Based on observation: LPA observed dead cockroach, bugs, overgrown shrubs, grass, and trees, broken down fountain, medical glove, dirty tissue, leaking bathroom sink at the resident's outside court yard and in bedrooms. This posed a potential risk to residents in care.
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Type B
10/07/2021
Section Cited

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Plan of Operation 87208(a)(7)(b) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...Sketches, showing dimensions, of the following:
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The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents. This requirement was not met as evidence by: based on observation, interview, document review, the facility did not ensure staff were not occupying resident rooms. This posed a potential 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: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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