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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:35:45 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
06/08/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210608093909
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342700597
ADMINISTRATOR:VICKIE KAISERFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 59DATE:
06/16/2021
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Gregory GreenTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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9
Residents apartment has infestation.
Resident's refrigerator is not working properly.
INVESTIGATION FINDINGS:
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On 06-16-2021 at 8:56 am, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Gregory Green and explained the purpose of today's visit.

LPA Martinez obtained facility and resident records, and conducted interviews with staff and residents. In addition, LPA Martinez toured the facility with Gregory Green and Marlene Bremer. During the facility visit, LPA Martinez observed dead cockroaches in Resident 1's apartment. Furthermore, 3 residents reported seeing cockroaches in their apartments. Moreover, during the visit, it was learned Terminix Pest Control has conducted cite visits in April of this year. Terminix Pest Control has implemented pest treatments, as there is a infestation of cockroaches throughout resident apartments and common areas of the facility. Furthermore, Terminix Pest Control visited the facility today and conducted a pest treatment.

Continued...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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-20210608093909
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: 06/16/2021
NARRATIVE
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In addition, LPA Martinez inspected resident 4's (R4) apartment. LPA Martinez inspected the bedroom, bathroom, and kitchenette. LPA did not observer any bugs or cockroaches. LPA Martinez inspected R4's refrigerator and observed mold in the freezer and Ice packs were not frozen. The refrigerator also contained a warm bottle of water and warm bottle of cranberry juice. During the inspection, the refrigerator was turned on and making a noise.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted with Gregory Green Copy of report, LIC 9099-D, and appeal rights provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
06/08/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210608093909

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342700597
ADMINISTRATOR:VICKIE KAISERFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 59DATE:
06/16/2021
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Gregory GreenTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not informing POA of fall/change in condition.
INVESTIGATION FINDINGS:
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On 06-16-2021 at 8:56 am, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced facility visit to open and close a complaint investigation with the above allegation. LPA Martinez met with Gregory Green and explained the purpose of today's visit.

LPA Martinez obtained facility and resident records, and conducted interviews with staff and residents. LPA Martinez reviewed facility Unusual Incident/Injury reports, and LPA Martinez observed a 04/25/2021 fall report and a 05/28/2021 left calf swelling report. Furthermore, both reports were provided to the Community Care Licensing Department. Facility documents indicate the 04/25/2021 and 05/28/2021 incidents were reported to the responsible party.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 5
Control Number 27-AS-20210608093909
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: 06/16/2021
NARRATIVE
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Furthermore, on 05/28/2021 R4 was sent out the hospital, and documentation states responsible party was called and was informed about R4 being sent out to the hospital. It was learned that R4 reported she did not fall, however, she reported she had pain on her left leg. A facility registered nurse conducted a health assessment and R4 was sent to the hospital. There is no other documentation that R4 sustained a fall on this day.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. There were no deficiencies given and an exit interview was conducted and copy of report provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210608093909
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: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited
CCR
87307(d)(2)
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87307(d)(2)Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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The facility administrator has a contract with Terminix Pest Control Company to conduct monthly pest treatments. Administrator agrees to conduct training on reporting pest/bug/rodent infestations by POC Date 07/02/2021. Administrator will email training materials by 07/02/2021
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This requirement was not met by: Based on interviews, observation, and file reviews, the licensee did not ensure the facility was clean/sanitary and healthful environment. The facility has a pest/cockroach infestation throughout the facility . This poses an potential health and safety risk to residents in care.
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Type B
07/02/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation...The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The facility administrator agrees to conduct a maintenance and operation training for staff by POC day 07/02/2021. Administrator will email training materials by 07/02/2021
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This requirement was not met by: Based on interviews and observation, the licensee did not ensure R4's apartment refrigerator was working properly. The refrigerator had mold growing in the freezer, and it was not keeping food and drinks cold. This poses an 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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5