342700597-6-28-2021-27-AS-KHOS-C4NHXG-20210706063503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 06/28/2021
Date Signed: 06/28/2021 03:14:15 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
06/21/2021 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210621155113

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342700597
ADMINISTRATOR:	VICKIE KAISER		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 59	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Tanysha Borromeo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident was locked out of facility.

INVESTIGATION FINDINGS:

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On 06-28-2021 at 1:11 pm, 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 Tanysha Borromeo and explained the purpose of today's visit.

LPA Martinez toured the facility and interviewed staff. LPA Martinez inspected all emergency exit doors and courtyard doors. Emergency exit doors are locked from the outside of the facility, as they are only used for emergency purposes. LPA Martinez tested the courtyard doors. LPA Martinez observed the courtyard doors to be unlocked and in good repair. The two courtyards are located within the main building, and all unlocked courtyard doors lead into facility.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210621155113

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: 06/28/2021

NARRATIVE

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Moreover, staff 1 (S1) reported there were no incidents of resident 1 (R1) being locked in the courtyards. Furthermore, witness 1 (W1) reported she was unaware of date R1 was locked in the courtyard. W1 reported she was unaware of how long R1 was locked out.

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, and no deficiencies were given. An exit interview was conducted, and a copy of this report provided to Tanysha Borromeo.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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