342701122-9-21-2023-27-AS-KHOS-CW3HZF-20230927063815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 09/20/2023
Date Signed: 09/21/2023 04:22:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230828113926

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: 103	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	12:00 AM
MET WITH:	Melissa Orelle		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not administer resident's medications as prescribed.

INVESTIGATION FINDINGS:

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On 09/20/2023, Licensing Program Analyst (LPA) Pang Lee and Licensing Program Manager (LPM) Czarrina Camilon-Lee arrived unannounced to this facility to conduct a complaint visit. LPAs met with administrator, Melissa Orelle and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 103. A brief interview with administrator assistant, Tasha Keitt and administrator, Melissa Orelle was conducted.

Allegation: Staff did not administer resident's medications as prescribed.

It was alleged that that the facility Staff did not administer resident's medications as prescribed. Throughout the course of the investigation, LPA Lee reviewed resident MAR sheets and conducted interviews. This investigation revealed that 4 out of 6 MAR sheets are incomplete for the month of July and August. The MAR Sheets indicated that resident’s medications are not being recorded; therefore, it is unclear if resident received their medications. Furthermore, LPA Lee interviewed 7 out of 10 residents who shared that their medications are not being administered from MedTech’s.
Continued LIC 9099-C

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: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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-20230828113926

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEGACY OAKS OF SACRAMENTO	FACILITY NUMBER: 342701122
	VISIT DATE: 09/20/2023

NARRATIVE

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It was learned that Administrator, Mellissa Orelle checks resident MAR sheets weekly. The administrator stated that if resident MAR sheets are incomplete, she will ask MedTech if medications was administered to residents and if so then MedTech will go back and initial their name indicating that residents’ medication was administered. In addition, on 08/21/2023 it was learned that MAR sheets for resident 1 (R1) which was provided to family members did not match MAR sheets provided to LPA Lee and Ombudsman Ron on 08/29/2023. When LPA Lee and Ombudsman Ron questioned administrator why R1 MAR sheets on 08/21/2023 and 08/29/2023 did not match administrator was not able to explain and shrug her shoulders.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within a 12-month period. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to 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: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230828113926

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LEGACY OAKS OF SACRAMENTO	FACILITY NUMBER: 342701122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees go to CCLD website and review approved vendors and sign up for training's in regards to medication training's for MedTech staff. Administrator will send LPA Lee at pang.lee@dss.ca.gov proof of registering for training's for MedTech by POC date of 09/26/2023.
	8 9 10 11 12 13 14	Based on observations, interviews and record review, the licensee did not comply with the section cited above in (4) out of (6) resident MAR sheets was not current and accurate, which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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