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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 11/08/2023
Date Signed: 11/08/2023 06:45:09 PM


Document Has Been Signed on 11/08/2023 06:45 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:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 106DATE:
11/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Laurie McConnellTIME COMPLETED:
06:00 PM
NARRATIVE
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On 11/08/23 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to perform a Case Management visit. The LPA identified herself, the purpose of the visit and asked to meet with the Designated Facility Administrator or Designee. LPA met with Laurie McConnell A brief interview followed.

During a tour of Memory Care, LPA pulled an emergency cord in the bathroom of one of the resident's rooms. Staff responded in 2 minutes and 2 seconds.

This Case Management visit pertained to incidents that were reported to have occurred on 11/01/23 and 2 others on 11/05/23. The incidents involved the aggressive behavior of R1. Upon reviewing R1's file, interviewing R1, Caregiver (S1), as well as the Director of Memory Care, R1 should have been re-evaluated and a new LIC 602 created when R1 had a change in living accommodations. R1 had a change in condition that required her to move from Assisted Living into Memory Care.

The LPA discussed this with the Director of Memory Care who attempted to contact the power of attorney for R1 about obtaining a new LIC 602.

According to the Code of California Regulations, Title 22, Division 6 a deficiency has been cited today and may be found on the LIC 809 D page.

A copy of this report was provided along with Appeal Rights.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/08/2023 06:45 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
87463(c)

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Reappraisals (c) The licensee shall arrange a meeting with ...health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
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Memory Care Director contacted the POA about a new LIC 602 to be completed and submitted to kimberly.viarella@dss.ca.gov by 11/22/23. Licensee shall provide training to staff on how to identify a change of condition and how to implement the
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The Licensee failed to comply with the above regulation when:
Based on file review, observation and interview, the licensee did not ensure that reappraisals were done for R1 which poses/posed a health and safety risk to residents in care as well as staff.
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interventions documented in the service plans. Training will be completed by 11/30/23 signature sheets of participants will be submitted to the email above.

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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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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