342700597-5-28-2021-27-AS-KHOS-C3LKBX-20210602074616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 05/28/2021
Date Signed: 05/28/2021 06:16:34 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
12/28/2020 and conducted by Evaluator Michael Reber

COMPLAINT CONTROL NUMBER: 27-AS-20201228152917

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 44	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Tanysha Borromeo, Business Office Manager		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Facility staff did not ensure that resident was adequately fed

INVESTIGATION FINDINGS:

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Analyst Mike Reber arrived at the facility today, 5/28/21, and met with Tanysha Borromeo, to deliver investigation findings to the above stated allegation. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.

**********************************Report continued on LIC 9099C********************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20201228152917

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: 05/28/2021

NARRATIVE

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********************************Report Continued from form LIC 9099******************************************

Allegation #1 - Facility staff did not ensure that resident was adequately fed

Analyst obtained records indicating that R1s physician has ordered R1 to receive double portions during meals. Analyst interviewed two caregivers and one med tech who state that R1 is offered double portions at all meals. Staff states that they do not automatically give R1 double portions she becomes upset and stressed that she is wasting food because she is unable to eat what is on the plate. Staff state that R1 is always offered larger portions or a second serving but usually R1 refuses when offered. Due to R1 cognitive deficits and language barrier, analyst was not able to communicate with resident to determine if she receives or if staff offer her double or extra portions during meals.

Based on information obtained, analyst finds the allegations to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.

Exit interview conducted. Copy of report left with staff.

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 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
12/28/2020 and conducted by Evaluator Michael Reber

COMPLAINT CONTROL NUMBER: 27-AS-20201228152917

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 44	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Tanysha Borromeo, Business Office Manager		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Facility staff did not follow resident's doctor's orders

INVESTIGATION FINDINGS:

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Analyst obtained medication administration records (MAR) for February, March and April of 2021. These records indicate that R1s physician has ordered R1 to receive an Ensure supplement twice daily. MAR documentation for February 2021 indicates that R1 was not given a supplement during dinner on 2/2, 2/26 and 2/27 and additionally, it does not indicate that the supplement was offered by staff and refused by R1. Further review of MAR documentation also indicates that the supplement was not given to R1 six times in March and five times in April of 2021.

Based on interviews conducted and records reviewed, this analyst finds the allegation to be SUBSTANTIATED - a finding that means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.Exit interview conducted. Copy of report and appeal rights provided to staff.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20201228152917

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5)The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Administrator shall submit a written statement detailing procedures that will be implemented to prevent missed doses of supplements/medications during each shift. In addition, conduct a training with all staff that administer medications regarding the new procedures to catch missed medications and attach the attendance sheet to the written statement.
	8 9 10 11 12 13 14	Based on documents obtained the Medication Administration Record indicates that R1 was not given her Ensure supplement 3 times in February, 6 times in March and 5 times in April. This requirement has not been met which poses a potential health and safety threat to the resident in care.	8 9 10 11 12 13 14	Please submit written statement and attendance sheet to LPA by POC due date of 6/11/21.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alycia Berryman	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Reber	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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