342700597-6-28-2021-27-AS-KHOS-C4NJLB-20210706070827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700597
Report Date: 06/28/2021
Date Signed: 06/28/2021 10:13:32 AM

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
04/22/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20210422164853

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:	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Office Manager Tanysha Borromeo		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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faciity is charging above SSI rate for admissions

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anthony Tuck conducted an unannounced visit to the facility on 06/28/2021 and was met by Office Manager Tanysha Borromeo. LPA explained the reason for the visit to deliver findings and conclude a complaint investigation.

The allegations are facility is charging above SSI rate for admissions.
LPA conducted phone interviews with the Executive Director (ED), Office Manager (OM), and Care Coordinator (CC). LPA received and reviewed documentation such as copies of Admission agreements for (2) residents. LPA also received and reviewed a revised admission agreement for Resident 1 (R1).

LPA received and reviewed copies of correspondence from CC with Department of Health Care Services on policies for assisted living waiver program guidelines (ALWP). Based upon review of ALWP guidelines and review of admission agreements, LPA found the admission agreement did not provide a comprehensive list of services and fees broken down. The admissions agreement did not provide an agreed upon amount for the resident to pay any extra monthly fees above the SSI rate as part of the ALWP guidelines.
Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
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-20210422164853

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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The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of
Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were
provided. Exit interview was conducted with Office Manager. Copy of the report was provided to Office Manager upon conclusion of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
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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Control Number 27-AS-20210422164853

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: 06/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/07/2021 Section Cited CCR 87507(g)(3)(A)1,2,3	1 2 3 4 5 6 7	87507 (g) Admission Agreements (3) Payment provisions...(A) Rate for all basic services... 1. A comprehensive description of any items... 2 description... corresponding fee... all basic services not included in the single fee shall be listed 3. Exempt-income-allowance may be included if the resident agrees to such charge.	1 2 3 4 5 6 7	Office manager agrees to contact the Care Coordinator to obtain the additinal detailed documentation for agreed upon rates and services being provided for ALWP recipients to be included in the admissions agreement and update the admissions agreement for ALWP recipients.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: The Licensee/Administrator failed to adhere to providing a comprehensive description of fees found in the admissions agreement which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	Office Manager will submit a comprehensive admissions agreement to LPA via email on 07/07/2021.
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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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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