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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:13:03 PM


Document Has Been Signed on 06/20/2023 04:13 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:AUDRE SMITHFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 93DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Alicia DuchineTIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/20/23 at 1:40pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address violations observed by LPA when they arrived at the facility. LPA met with Staff member Alicia Duchine to discuss LPA's observations.

When LPA arrived at the facility they observed two individuals in wheelchairs on the sidewalk before entering the facility. LPA made contact with both individuals who confirmed they are residents of the facility. When LPA met with staff members, LPA requested the LIC 602 (Physician Report) for both individuals. LPA reviewed the 602s and observed both 602s indicated both residents were determined by their physician to be unable to leave the facility unassisted. LPA did not observe any staff members in front of the building providing supervision to the residents. LPA discussed with the staff member and executive director the requirements for staff supervision any time a resident exits the facility and their 602 indicates they are unable to leave the facility unassisted.

Per California Code of Regulations, Title 22, the following deficiency is cited.

Exit interview conducted an a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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Document Has Been Signed on 06/20/2023 04:13 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
CCLD Regional Office, 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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by
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The facility will provide a written plan of correction indicating the steps the facility will take to ensure that residents, who have been determined to be unable to leave the facility unassisted, remain supervised by a staff member and the actions staff will take to ensure residents
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LPAs observations of residents being unsupervised who, per their 602, are unable to leave the facility unassisted and were in front of the facility but off the property on the side walk by the street which poses a potential health, safety and personal rights risk to residents in care.
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are supervised and/or redirected. Please include the training materials provided to staff to ensure the safety of residents.

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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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