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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:48:48 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 Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20211004133300
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:
10/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melissa OrelloTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision: Staff not providing assistance to residents in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Legacy Oaks of Sacramento on 10/27/21 at 11:15am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on LPA's observations and statements obtained during the investigation process, the allegations are substantiated because LPA observed the signal system to be deactivated in the memory care unit of the facility which confirms that staff could not respond to assistance in a timely manner as the system was shut off and no staff were alerted if a resident pulled the emergency cord for assistance.

The Department has determined the above allegation to be (S) Substantiated - meaning that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on LIC 9099-D of complaint control number 27-AS-20211015135537. Complaint date 10/15/2021.
Report continued on LIC 9099-C. 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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 4
Control Number 27-AS-20211004133300
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: 10/27/2021
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
Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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 Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20211004133300

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:
10/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melissa OrelloTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision:
1) Staff not maintaining residents hygiene.
2) Facility is understaffed.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended document. This document was created in error.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Legacy Oaks of Sacramento on 10/27/21 at 11:30am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because no clients interviewed identified any needs or services that were not provided by staff due to the facility being short staffed. LPA interviewed, R1, R2, R3 and R4, and none of the residents interviewed complained of long waits for services or lack of services being provided. LPA Gould interviewed seven staff members and no staff member could provide LPA with a specific residents or services not being provided by staff. Three of the seven staff interviewed stated there can be days when they are short staffed and the work is difficult but they meet the needs of residents. LPA observed staff are brought in from multiple outside agencies to supplement staffing.
Report Continued on LIC 9099-C. Page 1 of 2.
Unsubstantiated
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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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-20211004133300
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: 10/27/2021
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 interviewed R4 to ensure his hygiene needs are being met. R4 stated yes that he mostly work with the staff to ensure hygiene needs are being met including getting assistance with showering. Staff interviewed stated R4 does not like to shower and will often tell us he would like to go later. Staff will utilize resident's favorite activity to ensure resident showers.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

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

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4