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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:34:02 PM

Substantiated


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
01/26/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220126114848
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:
05/11/2022
UNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Melissa OrelloTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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-Resident sustained fractures while in care
-Staff did not inform responsible party of resident's change in condition
-Facility failed to seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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On May 11, 2022 at 1:26PM, 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 Resident sustained fractures while care, the Department found the following: based on medical record review it was determined that Resident 1 (R1) sustained multiple fractures throughout his/her body. Per Staff 1(S1), S1 witnessed R1 on the ground due to a fall.

Regarding the allegation of Staff did not inform responsible party of resident's change in condition, the Department found the following: based on interview, it was determined that R1's conservator was not informed about change of condition regarding R1.

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: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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-20220126114848
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: 05/11/2022
NARRATIVE
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Regarding the allegation of Facility failed to seek medical attention in a timely manner, the Department found the following: based on interview, it was determined that R1 had a change of condition 3 days prior to being sent out to the hospital.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegations above are SUBSTANTIATED. The following deficiencies are cited per California Code of Regulations, Title 22.

Civil Penalties for violations resulting in serious bodily injury is/are pending a departmental review at this time. Immediate civil penalty of $500 for serious bodily injury is being issued on May 11, 2022.

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: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220126114848
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: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
87464(f)(1)(c)
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Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care.
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Administrator has agreed to do an in-service training regarding care and supervision. Administrator has agreed to give copy of training to LPA by POC due date.
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This requirement was not met as evidenced by: Based on record review, the licensee did not ensure R1 received proper medical treatment due to sustained fractures. This poses an immediate health and safety risk to residents in care.
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Type A
05/12/2022
Section Cited
CCR
87211(a)(2)
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87211(a)(2) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Administrator has agreed to do an in-service on reporting Covid positives on time to responsible parties. Administrator has agreed to give copy of training to LPA by POC due date.
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This requirement was not met as evidenced by: Based on interview, the licensee did not ensure R1's conservator was contacted within 24 hours. 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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220126114848
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: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
87465(j)
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87465(j): Incidental Medical and Dental Care: (j) In all facilities licensed for sixteen (16) persons or more... assuring that each resident receives needed first aid and needed emergency medical services...
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Administrator has agreed to do an in-service training regarding timely medical attention. Administrator has agreed to give copy of training to LPA by POC due date.
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This requirement was not met as evidence by: based on record review the licensee did not ensure that R1 was sent to the hospital in a timely manner for change of condition.
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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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4