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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:17:57 PM


Document Has Been Signed on 10/24/2023 04:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 104DATE:
10/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Alicia DuchineTIME COMPLETED:
04:30 PM
NARRATIVE
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On10/24/23 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a complaint investigation. This case management is the result of information gathered during that visit and that did not pertain directly to the complaint investigation. The LPA met with Alicia Duchine, Director of Memory Care and a brief interview followed.

During each visit, LPAs confirm that all staff have completed their criminal background checks and have been associated to the facility. Based on a review of records, out of the 52 employees listed on the LIC 500, dated 10/23/2023, there were 4 employees who were background cleared, but were not associated to this facility. This is a violation of Title 22 of the California Code of Regulations and the deficiency is cited on the LIC 809D page.

A copy of this report and Appeal Rights provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 10/24/2023 04:17 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 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Licensee shall associate the 4 employees and submit proof of submission to Kviarella@dss.ca.gov by 5:00 PM on 10/25/23.
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This requirement was not met by the fact that a review of records showed that 4 out of the 52 employees listed on the LIC 500 were not associated to this facility in Guardian.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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