342700597-7-15-2021-27-AS-AMAZ-C4Y36T-20210715175853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700597
Report Date: 07/15/2021
Date Signed: 07/15/2021 05:59:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	MARLENE M BREMER		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 59	DATE:	07/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Gregory Green and Tanysha Borromeo		TIME COMPLETED:	06:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Manager Czarrina Camilon-Lee made an unannounced annual inspection visit on 07/15/2021 at 1:15 PM. LPA and LPM met with Gregory Green and stated the purpose of today’s visit. LPA and LPM inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 160 non-ambulatory residents. There are currently fifty-nine residents who reside at this facility, which two residents are receiving hospice care.

The LPA and LPM toured the facility with Gregory Green and Tanysha Borromeo on 07/15/2021 at 1:30 PM.

The facility did not have Covid-19 postings at exterior front door entrance. In addition, the facility did not have covid-19 postings that promote: hand washing, coughing/sneezing etiquette, and social distancing practices throughout the facility.

The facility was clean and facility common floor boards are not in good repair. The flooring has cracks and peeling. Common hallways have sufficient lighting. The facility temperature is 73 degrees. The facility’s hot water temperature is 110 degrees. The facility’s fire extinguishers were last inspected on 07/15/2021. The facility carbon monoxide and fire alarms are located on ceilings/walls. All carbon detectors were tested, and they are all in working order. The facility kitchen is sanitary, and has a monthly menu posted. The facility kitchen has a sufficient supply of perishable and non-perishable food. Non-perishable food cans have expirations dates on them.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

87303 Maintenance and Operation (a) (1) 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. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Facility common flooring had cracks and peeling, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2021
	Plan of Correction
1 2 3 4	Gregory Green has agreed provide a copy of the floor invoice and start date of the flooring repair. Gregory Green agrees to email the mentioned documents to LPA by POC date 08/09/2021

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Furthermore, two facility staff were not associated to the facility. Due to insufficient time, LPA Martinez will return to the facility at a later date and time to complete the annual inspection. As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted and 809, 809D, and appeals right given to Gregory Green.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e)(2)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above two care staff were not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Two staff were associated to the facility during the annual inspection. Gregory Green agrees to verify all newly hired staff are associated before their start date. Gregory will email LPA implemented association procedures by POC date 07/16/2021

Type A

Section Cited

HSC

1569.50(3)

§1569.50 (3) Denial, suspension or revocation of license; grounds; application of remedies; temporary suspension pending hearing; exclusion from licensure without right to petition for reinstatement. Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, such as, not conducting covid-19 pre-screening upon arrival and not following Covid-19 mitigation, which the facility did not have covid-19 postings throughout the facility. (hand washing, coughing/sneezing etiquette, and social distancing practices), which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2021
	Plan of Correction
1 2 3 4	Gregory Green agrees to post Covid-19 posting by 07/16/2021. Gregory Green agrees to email covid-19 posting by 07/16/2021.

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: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4