342700597-10-28-2021-27-AS-KHOS-C8EHK7-20211103061528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 10/28/2021
Date Signed: 10/28/2021 04:14:53 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
10/04/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20211004114105

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:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Office Manager Serina Villanueva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility has roaches

INVESTIGATION FINDINGS:

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LPA Anthony Tuck arrived at the facility location unannounced on 10/28/2021 and was met by Office Manger Serina Villanueva. LPA explained the reason for today's visit to conclude the investigation of the allegation listed above.

LPA conducted an initial visit on 10/06/2021. LPA toured the facility and inspected the kitchen, 2 hallway bathrooms, assisted living dining hall, TV room, and 8 resident rooms for pests. LPA received copy of pest control invoices. An additional inspection on 10/05/2021 was conducted by LPA Martinez on a separate complaint investigation Control# 27-AS-20211005092039. It was determined on a separate case management report that the facility was substantiated for having cock roaches. The facility was already cited for this allegation. No additional citations are being issued on this report.

Exit interview was conducted with Executive Director Melissa Orello and a copy of this report was left with the facility upon exit.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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

LIC9099 (FAS) - (06/04)

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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
10/04/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20211004114105

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:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Office Manager Serina Villanueva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are not maintaining a comfortable room temperature for residents

INVESTIGATION FINDINGS:

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LPA Anthony Tuck arrived at the facility location unannounced on 10/28/2021 and was met by Office Manger Serina Villanueva. LPA explained the reason for today's visit to conclude the investigation of the allegation listed above.
LPA conducted an initial visit on 10/06/2021, LPA received and reviewed a copy of an HVAC service invoice order for repairs dated 06/04/2021. LPA toured the facility. LPA inspected 7 resident rooms, kitchen, Assisted Living Dining Room, Memory Care Dining Room, main lobby and hallways checking room temperatures on thermostats and checking hallway room temperatures. The average room temperature was measured between 71-77 degrees Fahrenheit. LPA conducted 11 resident interviews and 8 staff interviews. This agency has investigated the allegation listed above. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
Exit interview was conducted with Executive Director Melissa Orello. Copy of the report was left with the facility upon exit.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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

LIC9099 (FAS) - (06/04)

Page: 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
10/04/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20211004114105

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:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Office Manager Serina Villanueva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are not supervising residents resulting in multiple falls and injuries

INVESTIGATION FINDINGS:

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LPA Anthony Tuck arrived at the facility location unannounced on 10/28/2021 and was met by Office Manger Serina Villanueva. LPA explained the reason for today's visit to conclude the investigation of the allegation listed above.

LPA conducted an initial visit on 10/06/2021. LPA conducted an interview with R1 on 10/06/2021. LPA conducted 2 phone interviews with R2 and R3 who are in memory care on 10/19/2021. LPA conducted interviews on 10/28/2021 with R4, R5, R7, R8, R9, R10 and R11 at the facility who are in assisted living. LPA learned that R6 was not at the facility today. Based on interviews with residents LPA learned that staff are quick to respond to call signal buttons in assisted living. LPA learned from interviews with residents in memory care that they have never been left unattended after a fall. LPA learned from interviews with memory care staff that safety checks are done every hour.
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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-20211004114105

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: 10/28/2021

NARRATIVE

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There is not substantial evidence to support or disprove that the alleged violations occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements; LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Executive Director Melissa Morello, a copy of the report was left with the facility upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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