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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 10/20/2021
Date Signed: 10/20/2021 01:53:46 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
10/15/2021 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211015135537
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:
10/20/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marlene Bremer, Assistant Executive Director (S1)TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Admission Agreement: Facility does not have a signal system for all residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Legacy Oaks of Sacramento on 10/20/21 at 10:45am to inform the licensee of complaint allegation mentioned above. LPA met with Assistant Executive director and was joined by the Administrator Melissa Orello at 1:00pm.

During this investigation LPA Gould reviewed all files and admission agreements for memory care residents. LPA observed that that admission agreement included a signed addendum documenting the receipt of the resident handbook signed by the resident or authorized representatives which indicates a signal system is available in all resident rooms. LPA and S1 toured the memory care unit and entered all rooms to inspect the emergency pull cords located in the bathrooms. LPA observed that the signal system in the memory care unit has been deactivated and LPA observed several rooms where the cord was pulled and had not been reset or indicated a need for assistance to the staff working in the memory care unit.

Report continued on next page: Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 3
Control Number 27-AS-20211015135537
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: 10/20/2021
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Admission Agreement is substantiated. The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the Administrator. Appeal Rights were issued, and a copy of this report was left at the Facility.

Page 1 of 2
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211015135537
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: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited
CCR
87303(i)(1)(A-C)
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Maintenance and Operation : Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.
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Administrator will have the signal system in the memory care unit operational by the plan of correction due date.
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(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.(C) Identify the specific resident living unit. This requirement was not met as evidenced by LPA's inspection of the memory care pull cords in residents rooms that were deactivated or not functioning as designed which poses an immediate health, safety or personal rights risk to reidents in care.
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Type B
10/27/2021
Section Cited
CCR
87507(f)
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Admission Agreements: The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by LPA's review of all resident files in memory care including Admission Agreements and Addendum D
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Administrator will review admission agreement and resident handbook. Administrator will resubmit a new copy of the admission agreement and all addendums within the admission agreement to community care licensing for approval by the plan of correction date.
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(resident handbook) which states there is a signal system in each resident bedroom Which poses a potential health, safety and personal rights 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: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3