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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 04/26/2022
Date Signed: 04/26/2022 04:03:00 PM

Unsubstantiated


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
01/20/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220120121405
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:0CENSUS: 0DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Melissa OrelloTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Staff did not assist residents with incontinence care
-Facility did not monitor resident's use oxygen equipment
-Staff do not assist resident with self administered medication
-Staff did not monitor resident for change in condition
INVESTIGATION FINDINGS:
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On April 26, 2022 at 3:10PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Administrator Melissa Orello and explained the purpose of today's visit.

Regarding the allegation of Staff did not assist residents with incontinence care, the Department found the following; based on interview and record review, it was determined that Resident 1's (R1) needs and services plan showed R1 was on 2 hour checks. Staff conducted those 2 hour checks and assisted with incontinence care based on R1’s care notes.

Regarding the allegation of Facility did not monitor resident's use oxygen equipment, the Department found the following; based on interview, it was determined that R1 was always seen by caregivers with oxygen on her face. Staff state they would check on the oxygen during their 2 hour checks and make sure it was always operable. Report Continued on LIC9099-C...
Unsubstantiated
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: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 4
Control Number 27-AS-20220120121405
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: 04/26/2022
NARRATIVE
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Regarding the allegation of Staff do not assist resident with self administered medication, the Department found the following; based on interview and record review, it was determined that as R1 started to decline staff helped with insulin in providing hand over hand assist. Although a photograph of medication sitting bedside was provided to LPA, there is a not a clear picture to determine what was taking place around the photograph.

Regarding the allegation of Staff did not monitor resident for change in condition, the Department found the following; based on record review R1’s blood sugar level was recorded and logged daily. When the Med-tech noticed R1 was in a unusual state, R1 was sent to the hospital, and the facility sent an Incident Report to CCLD detailing this incident.

LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview conducted with Executive Director Melissa Orello. A copy of this report was left with facility upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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
01/20/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220120121405

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:0CENSUS: 0DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Melissa OrelloTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Facility not maintained clean and sanitary
INVESTIGATION FINDINGS:
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On April 26, 2022 at 3:10PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Administrator Melissa Orello and explained the purpose of today's visit.

Regarding the allegation of Facility not maintained clean and sanitary, the Department found the following; based on interview and observation, it was determined that R1’s room was not maintained clean and sanitary. There were stacks of food in to-go boxes piled up on the kitchen counter, along with many cups. Once staff were made aware, R1’s room was cleaned by housekeeping and the Executive Director conducted an in service training. 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.
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: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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-20220120121405
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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:
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Administrator has agreed to conduct an in-service training for housekeeping staff. Administrator has agreed to send LPA written documentation of in-service training by POC due date 5/3/2022.
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Based on interview and observation, the Licensee did not ensure R1's room was clean and sanitary. This poses a potential 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: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4