342700597-11-1-2021-27-AS-KHOS-C8EJRS-20211103071713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 11/01/2021
Date Signed: 11/01/2021 12:52:21 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
10/05/2021 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20211005092039

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	LORI KNOLL		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 53	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Melissa Orello		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are not receiving medication as prescribed.
Resident's dietary plan is not being followed.
Resident rooms are unsanitary.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/01/2021 at 8:30 am to follow up on an open complaint investigation, LPA met with Administrator, Melissa Orello, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, toured the facility, and shadowed caregivers and med-techs during the morning and afternoon shifts. LPA Learned the following, resident 1 (R1) Ferrous Sulfate 325 MG was not administered on 10/25/2021 due to not refilling medication. R1's medication administration record (MAR) staff administration signature entry was also not entered for Ferrous Sulfate 325 MG on 10/24/2021. Additionally, staff administration signatures entries were not entered on 10/23/2021 and 10/25/2021 MAR for the following medication Fluoxetine, Alvesco, Melatonin, Dantoprazole, Metformin, Ducosate Sodium, and Simvastatin.

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: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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 7

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
10/05/2021 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211005092039

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	LORI KNOLL		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 53	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Melissa Orello		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are left in soiled briefs for an extended period of time.
Residents are not being fed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/01/2021 at 8:30 am to follow up on an open complaint investigation, LPA met with Administrator, Melissa Orello, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, toured the facility, and shadowed caregivers and med-techs during morning and noon shifts. LPA Martinez spoke with resident 1 (R1) and resident (R2) both residents reported they were independent, and able to manage their own incontinence care. Both resident reported they no issues or concerns with incontinence care. LPA Martinez reviewed resident 3 (R3) facility medical file. R3 medical file documents did not indicate any issues with incontinent care, additionally, staff reported care staff do not document when residents' briefs are changed. However, LPA Martinez was informed by staff that resident briefs are changed every two hours due to facility policy. As a result, there was not a preponderance of evidence to substantiate the allegation "Residents are left in soiled briefs for an extended period of time".
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: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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 7

Control Number 27-AS-20211005092039

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: 11/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Martinez visited the facility on 10/25/2021 and 10/26/2021. LPA Martinez observed food trays being served to residents. Additionally, R1 reported not having issues with meals being served and being fed. LPA Martinez was present in R1's room when her meal was being delivered. In addition, on 10/26/2021 LPA Martinez observed meals being served to other residents. In addition, LPA Martinez observed care staff feeding residents on 10/26/2021. LPA Martinez also visited the facility on 11/01/2021, and observed residents eating. As a result, there was not a preponderance of evidence to substantiate the allegation "Residents are not being fed".

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. An exit interview was conducted with Melissa Orello. A copy of this 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: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 27-AS-20211005092039

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: 11/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident 2's (R2) September 2021 MAR sheets did not have staff administration signature entries for Metoprolol, Potassium Chloride, Vitamin C, Vitamin D3, and Losartan on 09/19/2021 and 09/30/2021. Resident 3's (R3) September 2021 MAR sheets did not have staff administration signature entries for divalproer SOD Dr, Losartan Potassium, Metformin HCL ER, Tradjenta, Vitamin D3, Citalopram, Quetiapine, Atrovastatin, Donepezil on 09/21/2021, 09/22/2021, 09/24/2021, 09/25/2021, 09/28/2021, 09/29/2021, and 09/30/2021. As a result, residents are not receiving medication as prescribed.

LPA Martinez learned daily served meals are pureed and given to residents who require pureed diets. LPA Martinez visited the facility on 10/25/2021 and 10/26/2021. LPA Martinez observed the pureed meals on both days. LPA Martinez observed the food to be a very thick pureed consistency. Resident 4 (R4) requires a pureed diet. R4 reported the pureed diet meals are too thick and difficult to swallow. Furthermore, resident 5 (R5) reported being on a "No Added Salt-NAS diet". R5 reported there are no alternative meals to meet his special diet needs.

LPA Martinez returned to the facility on 11/01/2021 and observed R4's pureed diet, which was thick and chunky. R4 reported the pureed meal was too think and reported having issues with swallowing and would like a thinner consistency. LPA Martinez also reviewed special diet orders for R2. R2's medical file included a LIC 602 dated 10/29/2021, which reported yes, special diet, but no specification on what the special diet consisted of. The last dated Dietary Physician's order 03/11/2016, and stated, " mechanical soft chopped diet (provides a texture modification diets, which includes ground meat and omits certain raw and hard foods to chew)." However, during the 10/25/2021, 10/26/2021 and 11/01/2021 visits, R2 has was given a pureed diet. At this time, it is unknown what kind of special diet R2 should be on.

R6's 08/11/2021 special diet order consisted of puree diet and double portions for all meals. However, a newly dated 10/29/2021 LIC 602 states, "special diet: mechanical soft." LPA Martinez visited the facility on 11/01/2021, and R6 was served a pureed diet for breakfast. R7 is on a pureed diet, however, there is no special diet order for R7. During 11/01/2021 visit, R7 was given a pureed breakfast meal. Based on observation and file reviews, the facility is not following resident's dietary plan.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 27-AS-20211005092039

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: 11/01/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During a 10/25/2021 case management visit, the facility was cited 87303 Maintenance and Operation due to resident rooms being unsanitary. The facility was given a plan of correction, and the facility is currently working on correcting the 87303 Maintenance and Operation. The citation can be found on the 10/25/2021 case management report. There will be no citation given at today's visit 11/01/2021.

As a result of this investigation, the Department finds the allegations to be substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview conducted with Melissa Orello. A copy of this report and the LIC 9099-D, and appeal rights were provided. Failure to correct any deficiencies by plan of correction due dates may result in civil penalties.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 27-AS-20211005092039

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: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/26/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 (a)(5) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: Based on observation: The licensee did not	1 2 3 4 5 6 7	Facility staff agrees to conduct a medication audit by a third party audit company by POC Date: 11/26/2021. Facility staff agrees to email LPA Martinez audit date and company information by 11/15/2021.
	8 9 10 11 12 13 14	ensure R2 and R3 were being the medication prescribed as ordered by their primary care physicians. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 11/26/2021 Section Cited CCR 87458(b)(4)	1 2 3 4 5 6 7	87458 (b)(4) Medical Assessment: The medical assessment shall include, but not be limited to: Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations.	1 2 3 4 5 6 7	Facility staff agrees to conduct a internal medical assessment audit by POC Date:11/26/2021. Facility staff agrees to email LPA Martinez audit date and procedures by POC Date 11/15/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on observation: The licensee did not ensure R2, R6, and R7 had a updated special diet physician order and following special diet orders. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 27-AS-20211005092039

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: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/26/2021 Section Cited CCR 87464(f)(3)	1 2 3 4 5 6 7	87464 (f)(3) Basic Services: Basic services shall at a minimum include: Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, General Food Service Requirements.	1 2 3 4 5 6 7	Facility staff agrees to conduct a nutrition audit by a third party audit company by POC Date: 11/26/2021. A qualified nutritionist, or a dietitian, or a home economist shall conduct the audit.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on observation: The licensee did not ensure R4 and R5 were given low salt or other modified diets prescribed by their doctors. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Facility staff agrees to email LPA Martinez audit date and company information by 11/15/2021.
	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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 7