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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700741
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:45:17 PM


Document Has Been Signed on 10/11/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LEGGS RESIDENTIAL ADULT CARE IIFACILITY NUMBER:
342700741
ADMINISTRATOR:LEGGS, BRADFORD TFACILITY TYPE:
735
ADDRESS:10044 TWIN CITIES ROADTELEPHONE:
(707) 332-1262
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:6CENSUS: 3DATE:
10/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kiesha LeggsTIME COMPLETED:
04:00 PM
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On 10/11/23 at approximately 1:15pm Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct a post licensing inspection visit. LPA met with the Kiesha Leggs and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 7 bedrooms and 6 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 3 ambulatory residents.

Facility Observation: Upon entry the residents were in their rooms or at the gym. One resident was putting away laundry. One resident began his laundry during visit. LPA observed shaded outdoor room with porch swing, foosball table and seating area. TV room had large format TV and six player play station. Residents’ rooms contained personal items.

During this inspection 3 of 3 resident files and 2 of 7 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances.
Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Water temperature in common bathroom reads 119*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGGS RESIDENTIAL ADULT CARE II
FACILITY NUMBER: 342700741
VISIT DATE: 10/11/2023
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Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 9/29/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for residents' use. LPA reviewed facility’s disaster plan to ensure regulatory compliance.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Phyllis Leggs.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023
LIC809 (FAS) - (06/04)
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