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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 02/14/2022
Date Signed: 02/14/2022 01:01:45 PM


Document Has Been Signed on 02/14/2022 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SACRAMENTOFACILITY NUMBER:
342700597
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 51DATE:
02/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Melissa OrelloTIME COMPLETED:
01:05 PM
NARRATIVE
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On February 14, 2022 at 11:50am Licensing Program Analyst (LPA) Chris Hopkins arrived at Legacy Oaks of Sacramento and conducted an unannounced case management visit to follow-up on NCC conducted back in July 2021. LPA met with Executive Director Melissa Orello and stated the purpose of this visit.

Executive Director and LPA toured the facility. LPA observed some residents eating lunch, and maintaining social distancing. LPA observed all staff wearing face masks properly. LPA observed a fully stocked PPE supply room. LPA observed signs related to hand washing, social distancing, and how to don and doff posted throughout the facility. LPA observed employee and visitors logs to be complete with temperature, name, time in and time out sections all filled out properly. Staff training is conducted once a month, and if need be management conducts training when necessary. LPA observed training logs. LPA reviewed Admission Agreement to make sure it includes ALWP and SSI. LPA reviewed the LIC 808 mitigation plan. LPA observed a full isolation cart equipped with face shields, N95's, gowns, gloves, and hand sanitizer. LPA observed resident refrigerator to be cleaned and properly functioning. Residents have received their Change of Ownership notice. This notice was also provided to LPA as well. The facility does allow visitors whether or not they are vaccinated. Visitors must provide proof of vaccination if vaccinated. Visitors are now being tested.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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