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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 10/25/2021
Date Signed: 10/25/2021 05:40:08 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: 53DATE:
10/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Melissa OrelloTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/25/2021. LPA met with Melissa Orello 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 room 5's bathroom door was locked, and resident 1 was not able to use the bathroom. In addition, there were ceiling leaks throughout the facility. Resident 2 had to be relocated to another room. R2's furniture will be moved to another room 10/26/2021. Room 10 and Room 80 trash cans were overflowing with trash. Room 10 trash can was not emptied on 10/23/2021 and 10/24/2021. Room 67 did not have soap. Room 38's bathroom toilet was unsanitary. Additionally, resident washer is broken and has been broken for 10 days. Also, women's hallway bathroom trash can was not emptied and did not contain toilet seat covers.

As a result, deficiencies can be found on the 809-D report. An exit interview was conducted with Melissa Orello, 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: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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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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: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited

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87303 Maintenance and Operation (a) The 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 overflowing trash cans, locked resident bathroom, leaks throughout the facility, no soap in room 67, broken washer, ripped flooring in room 5, and ETC. This posed a potential room risk to residents in care.
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Clean hallway bathrooms and replenish toilet seat covers by plan of Correction (POC) date 11/05/2021. LPA Martinez will correct POC by visit.

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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: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021
LIC809 (FAS) - (06/04)
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