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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 06/23/2023
Date Signed: 06/23/2023 08:40:49 AM

Unsubstantiated


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 SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:AUDRE SMITHFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 94DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tasha KeittTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Staff mishandling residents medication.
Staff stole residents money.
Staff providing resident with spoiled meal(s).
Staff not keeping facility free from pests.
INVESTIGATION FINDINGS:
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On 06/23/2023 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee and Licensing Program Manager Czarrina Camilon-Lee arrived at the facility unannounced to deliver complaint findings. LPA Lee and LPM Camilon-Lee met with Memory Care Coordinator, Tasha Keitt the Current census is 94.

Throughout the course of this investigation, LPA Lee toured the facility, conducted staff and resident interviews, and reviewed facility files and records.

Regarding the allegation: Staff mishandling resident’s medication, based on residents’ interviews sixteen out of twenty residents did not have any complaints or concerns and stated that they were given their correct medications. An interview with two Med-Tech staff was also conducted and it was denied that Med-Tech staff are mishandling residents’ medications. It is unclear at this time if staff mishandled resident’s medication.
Continued on LIC 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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 SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:AUDRE SMITHFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tasha KeittTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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9
Staff not administering medication as prescribed.
INVESTIGATION FINDINGS:
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On 06/23/2023 at 9:00 AM, Licensing Program Analyst (LPA) Pang Lee and Licensing Program Manager Czarrina Camilon-Lee arrived at the facility unannounced to conduct a complaint visit. LPA Lee and LPM Camilon-Lee explained the purpose of the visit. The purpose of the visit was to deliver complaint findings. LPA Lee and LPM Camilon-Lee met with Memory Care Coordinator, Tasha Keitt. Current census is 94.

Throughout the investigation, LPA Lee conducted interviews and reviewed facility documents. LPA Lee was informed by two facilities staff that Med-Tech staffs are not properly documenting MAR sheets. Facility staff gave LPA Lee two Inservice training sign in sheets. One training was held on 06/08/2023 for “signing E-MAR Documenting” and the other training was completed on 06/06/2023 for “Med Room Training.” LPA Lee reviewed 1 April MAR sheet and it was not complete. LPA Lee also reviewed 5 May MAR sheets and 3 out of 5 MAR sheets were not complete and recorded. It is unclear if medications were given to residents.
Continued on LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87465(d)(3)
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87465 Incidental Medical and Dental Care
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication….
(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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The facility will have an outside agency conduct a training on medication administration, medication storage, medication ordering and medication verification for med-techs. Facility Administrator stated that a review of the section, 87465(d)(3), will be conducted. A statement of correction, along with proof of training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at pang.lee@dss.ca.gov by the due date of 07/07/2023 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed. Administrator will email LPA a training agenda and the agency conducting the training by 07/07/2023.
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Based on observation and file review, the Licensee did not ensure the residents Medication Administrator record was completed to reflect the medication that was administered. This posed a potential health, safety, and personal rights risks to the persons in care.
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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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
VISIT DATE: 06/23/2023
NARRATIVE
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As a result of this investigation, the Department finds these allegations 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.

An exit interview was conducted, and a copy of the 9099 report, 9099-D page, and appeals right document were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
VISIT DATE: 06/23/2023
NARRATIVE
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Regarding the allegation: staff stole residents’ money, based on interviews, nineteen out of twenty residents did not have any concerns and have not witnessed any facility staff stealing residents’ money. It is unclear at this time if staff stole resident’s money.

Regarding the allegations staff providing resident with spoiled meals. Based on interviews, thirteen out of twenty had no concerns with meals provided to them. On 05/09/2023, 05/16/2023 and 06/08/2023 facility visits, LPA Lee observed breakfast and lunch being served and had no concern with the meals being served. Meals provided to residents did not look spoiled. It is unclear at this time if staff is providing resident with spoiled meals.

Regarding the allegation: Staff not keeping facility free from pest. Based on interviews, fourteen out of twenty residents have no concerns and have not seen any pest in the facility. During 05/09/2023, 05/16/2023 and 06/08/2023 facility visits, LPA Lee did not observed any evidence of pest in the facility. LPA observed three mouse traps but there were no evidence of any mouse caught. Further, LPA observed a dead roach on the wall in the hallway. Facility was sanitary and clean during all LPA Lee facility visits. LPA Lee also observed housekeeper cleaning throughout the facility during all visits. Based on facility record, California Pest Control has been coming to the facility to conduct services in January 2023 to present. LPA Lee obtained service Inspection report for the following dates 02/02/2023, 03/14/2023, 04/11/2023, 05/09/2023 and 05/23/2023. Based on interviews, thirteen out of thirteen staff stated that they have not seen any pest in the facility. It is unclear at this time if staff is not keeping facility free from pest.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5