342700597-6-21-2021-27-AS-KHOS-C49NJK-20210623103029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 06/21/2021
Date Signed: 06/21/2021 10:24:24 AM

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
03/12/2021 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210312140314

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 60	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	ADMINISTRATOR - GREGORY GREENE		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Inadequate Staffing for medication distribution

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery finding for a complaint investigation received on 3/12/2021. LPA phoned facility for prescreening for COVID-19 precautions.An alyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit. LPA discussed with Administrator the conclusion for complaint and the finding.
During the investigation, LPA reviewed documents including, but not limited to four resident files (R’s 1-4); Medical Records, Physician Reports, Medication Administration Records (MARS), Staff Phone Numbers, and Centrally Stored Medication Logs. LPA interviewed current administrator, and family members. Previous management company wiped all the computers clean onsite. New management company West Bay Senior Living became effective April 1, 2021.

It was determined in the course of the investigation based on the information provided through documentation and staff interviews that the facility has had a shortage of staffing in February and March of 2021. Facility also had a full-time Medication Technician (MT) on temporary leave. During those months listed above, facility had thirty-five staff for all the shifts and positions. Facility is still working on having adequate staffing; caregivers and MT's have been working double shifts to help for coverage.
The allegation Inadequate Staffing for medication distribution was substantiated meaning that there was a preponderance of evidence to prove that the allegation occurred as reported. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. The following deficiencies were cited on 9099-D per Title 22, Division 6 of the California Code of Regulations.
Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted with Administrator. Copy of the reports were provided to Administrator LIC 9099, LIC 9099-D, Appeal Rights, Confidential Names list (LIC811), and Client Record Review (LIC 858).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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

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
03/12/2021 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210312140314

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 60	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	ADMINISTRATOR - GREGORY GREENE		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Residents are not receiving medication as prescribed
Facility staff are giving false statements

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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 5

Control Number 27-AS-20210312140314

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: 06/21/2021

NARRATIVE

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Continued from 9099 Page 2

During the investigation, LPA reviewed documents including, but not limited to four resident files (R1’s); Medical Records, Physician Reports, and Medication Administration Records (MARS). LPA interviewed current administrator, and family member. Previous management company wiped all the computers clean onsite. New management company West Bay Senior Living became effective April 1, 2021. LPA did not find any evidence of facility staff giving false statements due to the high level of hiring, firing, new ownership, and management company

It was determined in the course of the investigation based on the information provided through documentation and staff interviews that the allegation Facility staff are giving false statements is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be Unsubstantiated.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations.

Exit interview was conducted with Administrator. Copy of the reports were provided to Administrator LIC 9099-A, Confidential Names list (LIC811), Client Record Review (LIC 858), and Appeal Rights.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 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
03/12/2021 and conducted by Evaluator Ruth Wallace

COMPLAINT CONTROL NUMBER: 27-AS-20210312140314

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 60	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	ADMINISTRATOR - GREGORY GREENE		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Resident fell and did not receive adequate medical care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery finding for a complaint investigation received on 3/12/2021. LPA phoned facility for prescreening for COVID-19 precautions.An alyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit. LPA discussed with Administrator the conclusion for complaint and the finding.
During the investigation, LPA reviewed documents including, but not limited to one resident file (R1’s); Medical Records, Physician Report, and Medication Administration Records (MARS). LPA interviewed current administrator, and family member. Previous management company wiped all the computers clean onsite. New management company West Bay Senior Living became effective April 1, 2021.

It was determined in the course of the investigation based on the information provided through documentation and staff interviews that R1 did receive adequate medical care and R1’s responsible party (RP) was contacted each time R1 went to the emergency room. In addition, RP was notified by facility regarding any changes of health or care conditions. RP is satisfied with care of R1 who has been at facility for approximately five years.
The allegation Resident fell and did not receive adequate medical care was UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. We have therefore, dismissed the complaint.
No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations.
Exit interview was conducted with Administrator. Copy of the reports were provided to Administrator LIC 9099-A, Confidential Names list (LIC811), Client Record Review (LIC 858), and Appeal Rights.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210312140314

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: 06/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited CCR 87405(h)(4)	1 2 3 4 5 6 7	B Deficiency 87405 (h)(4) Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan via email to LPA by 6/28/21 as to how the facility will ensure recruitment, employ, and training qualified staff will be maintained for the health and safety of residents in care. ruth.wallace@dss.ca.gov
	8 9 10 11 12 13 14	Based on LPA’s review of resident (R1’s) medical documents, interviews, and observations the licensee did not recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. Facility was short of staff during the months of February and March of 2021, there were only 35 staff for all three shifts and positions. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5