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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 02/08/2022
Date Signed: 02/08/2022 04:27:16 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
01/13/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220113123342
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:
02/08/2022
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Melissa OrelloTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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-Staff mishandled a resident's medication while in care
INVESTIGATION FINDINGS:
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On 2/8/2022 at 2:58 PM, Licensing Program Analyst (LPA) Chris Hopkins arrived at this facility unannounced to conduct a complaint investigation regarding the above allegations. LPA met with Executive Director Melissa Orello and explained the purpose of today's visit.

Regarding the allegation of Staff mishandled a resident's medication while in care, the Department found the following: based on interview it was determined that Staff 1 (S1) went to the pharmacy to pick up Resident 1's (R1) medication after he/she got off of work. S1 then brought the medication back to R1's room and gave it to R1 without checking it in to the medication room. After dropping off the medication to R1, S1 immediately left the facility and went home. S1 denied taking any medication out of the bottle. S1 came back to work for her scheduled shift, and grabbed the medication out of R1's room, and brought it to the med-tech and alerted the Executive Director of what took place.

Report Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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 3
Control Number 27-AS-20220113123342
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: 02/08/2022
NARRATIVE
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Executive Director (ED) conducted her own investigation as well, and it was determined that S1 was at fault for getting and bringing R1's medication to his/her room and giving to R1. S1 was reprimanded and written up.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Staff mishandled a resident's medication while in care is SUBSTANTIATED. The following deficiencies are cited per California Code of Regulations, Title 22.

Exit interview was conducted with the Executive Director. 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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220113123342
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: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2022
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h): The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Administrator has agreed to conduct a in-training for med-techs and caregivers regarding medications. Administrator has agreed to send LPA written documentation of in-service training by POC due date 2/9/2022. Administrator has also removed S1 from Med-Tech duties.
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Based on Interview, the Licensee did not ensure that R1's medication was centrally stored and inaccessible. This poses an immediate health and safety 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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3