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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 10/29/2021
Date Signed: 10/29/2021 04:43:25 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 Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211005121011
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:
10/29/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa OrelloTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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staff are mismanaging residents medications
staff failed to report incident to CCL
the Administrator and staff are sleeping in designated resident rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 10/29/2021 at 9:00 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator, Melissa Orello, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility. Based on the interviews and statements obtained during the investigation process, LPA Truong learned that resident (R1) medication (Hydrocodone) went missing on around 9/18/21. A record of each dose was not recorded and maintained in the resident's record. In addition, staff (S4) stated that sometime resident med doesn’t get refill on time.

Report continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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 5
Control Number 27-AS-20211005121011
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: 10/29/2021
NARRATIVE
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The complaint also alleged that staff failed to report incident to CCL. Based on interviews and reviewed of records, resident (R3) sustained injuries from an un-witness fall on 9/25/21. R3 reported that she was in pain and the right side of her face was swollen. EMS was contacted and R3 was sent out for further evaluation. LPA reviewed facility electronic file and was not able to find this incident been reported. There was also no incident report found regarding missing medication of resident R1 mentioned above.

In addition, the complaint alleged that the Administrator Lori Knoll and staff are sleeping in designated resident rooms. Based on interview with ED Lori Knoll, she admitted that she and her son (S2) live in the facility room 36. ED also stated staff (S6) also live in the facility room 48. This citation can be found on the 10/6/2021 case management report. There will be no citation given at today's visit 10/29/2021 for this deficiency.

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, 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211005121011

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:
10/29/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa OrelloTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff falsify residents medication
Staff interacted with resident in a physically inappropriate manner
Resident's injuries were not properly tended to
Staff made an inappropriate comment towards resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 10/29/2021 at 9:00 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator, Melissa Orello, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility. Based on interviews and statements obtained during the investigation process, staff (S2), (S3) and (S4) all stated that they did not falsify resident mediation or being told to falsify signing off the MAR sheet. However, S2 stated that there are some discrepancies with resident’s MAR sheet. S2 reported that the MAR sheet was signed off, but medication was not being provided to the resident on one occasion.

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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 5
Control Number 27-AS-20211005121011
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: 10/29/2021
NARRATIVE
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The complaint alleged that staff interacted with resident in a physically inappropriate manner. Based on the interviews and statements obtained during the investigation, it was determined that there was insufficient evidence to substantiate that staff interacted with resident in a physically inappropriate manner. Staff (S2), (S3) and (S4) all reported that they did not witness any staff interacted with resident in appropriately. Staff S2 denied ever interacted with resident inappropriately. Resident (R4) was not able to recall or speak on the incident.

The complaint alleged that resident’s injuries were not properly tended to. Based on the interviews and statements obtained during the investigation, it was determined that there was insufficient evidence to substantiate that resident’s injuries were not properly tended to. S2 stated that he cleaned the dry blood off R3’s face with toilet paper and didn’t noticed any injuries. S2 denied using toilet paper that has feces to clean R3’s face. Resident R3 was not able to provide LPA Truong any information regarding the incident.

The complaint alleged that staff made an inappropriate comment towards resident. Based on the interviews and statements obtained during the investigation, it was determined that there was insufficient evidence to substantiate that staff made an inappropriate comment towards resident. Resident R2, R5 and R6 stated that they were not aware of any staff making inappropriate comment towards residents.

Based on information obtained, the department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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.

Exit interview was conducted with Administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211005121011
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: 10/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2021
Section Cited
CCR
87465(h)(2)
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87465(h)(2). Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication…a record of each dose is maintained in the resident's record.

This requirement is not met as evidenced by:
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The administrator agrees to provide in-service training with all medication technicians regarding managing medication. Proof of enrolling shall be submitted to LPA by 11/1/2021.

Administrator shall submit proof of training along with signatures of staff that participated in the training to LPA upon completion.
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Based on LPA’s observation and reviewed records, the Licensee did not properly managed resident's medication. R1’s medication went missing on 9/18/21 and there was no record of each dose in resident’s record, which poses an immediate health and safety risk to the residents in care.
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Type A
11/01/2021
Section Cited
CCR
87211(a)(2)
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87211(a)(2). Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following . . . Any incident which threatens the welfare, safety or health of any resident . . .

This requirement is not met as evidenced by:
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Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 11/1/2021.
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Based on interviews and records reviewed, the Licensee did not report incidents to the Community Care Licensing Division (CCLD) as required by Title 22. Incident report was not submitted to Licensing for R1's missing medication on 9/18/21 and R2 suffered injuries from a fall on 9/25/21. This poses an immediate health and safety risk to the residents in care.
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Administrator shall provide a written statement that she has reviewed the section cited in the regulation by proof of correction due date.
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: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5