342701122-5-16-2023-27-AS-PLEE-CRVUWR-20230516155711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:57:20 PM

Document Has Been Signed on 05/16/2023 03:57 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	AUDRE SMITH		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 92	DATE:	05/16/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Melissa Orello		TIME COMPLETED:	04:10 PM

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Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 05/16/2023 at 10:49 AM to conduct a proof of correction (POC) case management visit. LPA Lee met with Melissa Orello and explained the purpose of the visit.
The purpose of this visit is to follow-up on a plan of correction that were due on 05/15/2023. During today's visit, LPA Lee toured and inspected the facility to ensure deficiency previously cited on 05/09/2023 have been corrected.

During today's visit, LPA Lee toured the facility and inspected the kitchen to ensure that the two seven feet freezer has been purchased and installed. LPA Lee observed that licensee did ensure that the two seven feet freezer is installed and in working condition. Through observation, LPA Lee observed not sufficient 2 days perishable food in the two the freezer. LPA Lee observed five big bags of potato slices, and four bags of big french fries along with three boxes of ice cream in the two freezer. LPA Lee asked the kitchen chief where they were storing the poultry and kitchen chief informed LPA Lee that they kept the poultry in the walk in refrigerator due to thawing it out for the next day. LPA Lee observed one 6-10 pounds of boneless pork loins, one unopen box of 15 pounds of bacon with one used open box of bacon. LPA Lee also observed one unopen box of 10 pounds of pork sausage links along with one used open box of pork sausage links. LPA also observed one unopened ground sausage in the walk-in refrigerator for 90 residents in care.

Based upon this inspection, LPA Lee observed the following:

I. Deficiency cited under Title 22 Regulation 87303(a) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO	FACILITY NUMBER: 342701122
	VISIT DATE: 05/16/2023

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LPA Lee also follow up on a case management in regards to an email received on 05/09/2023 from the facility in regards to a administrator change. on 05/09/2023 LPA arrived to the facility unannounced to open a complaint and learned that there was a change in administrator on 05/04/2023. An administrator certificate was emailed to LPA Lee on 05/11/2023; however, the administrator certificate had expired on 03/23/2023. On 05/16/2023. LPA Lee learned that administrator certificate was not post marked until 04/07/2023. The facility did not ensure they notify the department of administrator change and ensure that administrator change was approve by the department.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO	FACILITY NUMBER: 342701122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87405(f)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (f) The administrator in facilities licensed for fifty (50) or more shall have two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency.	1 2 3 4 5 6 7	The Licensee will have an administrator designated to the facility by providing required documents to Licensing by POC 05/19/2023. These documents include LIC 200, LIC 500, administrator certificated, LIC 501 personnel record, Criminal record clearance, ID and appointed by the licensee.
	8 9 10 11 12 13 14	This regulation was not met as evidenced by: The licensee did not ensure that the facility had a current certified administrator. Based on information provided, the administrator was terminated, and no person with a valid certificatate who is approved is managing the facility. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/19/2023 Section Cited CCR87555(b)(26)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.	1 2 3 4 5 6 7	Kitchen chief stated they are geting a delivery from Sysco scheduled to arrive on 05/16/23 between the hours of 6:00 AM to 10:00 AM. Licensee will send LPA Lee pictures of sufficent two days perisable food and poultry in refridgerator and freezer along with a copy of the receipt to LPA Lee by POC due date 05/19/2023.
	8 9 10 11 12 13 14	Based on observations, the licensee did not ensure to have a sufficient amount of non-perishable foods or perishable foods at the facility, which poses an potiential health and safety risk to persons in care.	8 9 10 11 12 13 14

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) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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