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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:23:25 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
10/04/2021 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: DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Assistant Executive Director, Maureen BremerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is understaffed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Legacy Oaks of Sacramento on 11/4/21 at 1:45pm to conclude the investigation of the above allegation 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 have been corroborated because of observations made by LPA Martinez on an unrelated complaint inspection. LPA Martinez observed R1 request for PRN medication for pain and had to wait an extended time for the PRN. by the time PRN was able to be administered a higher level of pain medication was required. Per LPA Martinez there were three resident who require assistance with feeding selves and had to wait for staff to feed/serve other residents before receiving assistance from staff. LPA Martinez also observed several rooms which had trash and soiled diapers that had not been disposed of in a timely manner due to lack of adequate staff to meet the needs of residents.
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: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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-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: 11/04/2021
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility Assistant Executive Assistant. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
87411(a)
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Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section
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POC will include increasing housekeeping staff to seven days per week from five days per week to ensure cleaning needs are met. A job fair will be held to attract new staff and caregivers. Administrator will ensure there will be 2 caregivers and 1 medtech on each wing of facility. Facility will submit new LIC 500 with new personnel included and the dates and times of their shifts so that the department can confirm the staffing meets the needs of residents. Facility will submit written plan for job fair and to schedule no more than 30 days from the POC due date.
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 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services this requirement was not met as evidenced by LPAs observations of services that were delayed or not completed as a result of inadequate staffing which poses an immediate health, safety or personal rights risk to residents in care.
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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: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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
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: DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Assistant Executive Director, Maureen BremerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect/Lack of Supervision:
1) Staff not maintaining residents hygiene.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Legacy Oaks of Sacramento on 11/4/21 at 1:45pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

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.
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: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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-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: 11/04/2021
NARRATIVE
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5