342701122-5-9-2023-27-AS-KHOS-CTMJ49-20230711064244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:04:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
05/03/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230503110551

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: 90	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Melissa Orello		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility freezer is in disrepair.

INVESTIGATION FINDINGS:

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On 05-09-2023 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to open a complaint investigation. LPA Lee met with Administrative Assistant, Alicia Duchine and then was later joined by Administrator Melissa Orello. LPA Lee explained the purpose of today's visit to both Administrator and Administrator Assistant. Administrator assisted with today's visit. The current census is 90.

LPA Lee conducted interviews and toured the facility. LPA Lee toured the kitchen at 9:10 AM and learned that the facility walk-in freezer is broken. It was also learned that frozen produce was stored in a vacant resident medium refrigerator for 90 residents. During the investigation it was also learned that pork loins and diced ham cubes had to be thrown away due to the lack of space in the resident’s freezer since the pork loins and diced ham cubes has been delivered on 05/06/2023

As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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-20230503110551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/01/1987 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation 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.	1 2 3 4 5 6 7	Administrator purchased two seven feet freezer from Amazon. Administrator gave LPA Lee copy of purchased. Administrator stated that the two seven feet freezer will be delivered on Friday 05/12/2023 by 10:00 PM. Administrator will email LPA Lee pictures of the purchased freezers by 05/15/2023 by 5:00 PM.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations and interview the licensee did not ensure that the facility freezer was operating and in good repair.	8 9 10 11 12 13 14	Administrator stated that the bid through Heating and Air CJC for the broken freezer has been approved. Administrator is waiting on parts to be deliver to fix the freezer. Start date to fix the broken freezer is pending Administrator will let LPA Lee know when the start date will be.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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