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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:38:49 PM


Document Has Been Signed on 11/15/2023 04:38 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: 102DATE:
11/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Laurie McConnell and Schekesia Meadough TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Pang Lee and (LPA) Avelina Martinez arrived at this facility unannounced on 11/15/2023 at 3:00 PM to conduct a case management visit. LPAs met with Vice President of Operations, Laurie McConnell and Vice President of Health and Wellness, Schekesia Meadough and explained the purpose of today's visit. The census is 102.

The purpose of the visit is to follow up on deficiency learned during complaint investigation 27-AS-20230914141240. Through the complaint investigation, it was learned that the facility was not in good repair. LPAs observed resident room # 16 laminate floor peeling off the concrete which is an health and safety tripping hazard risk to resident in room #16.

The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeal rights were given 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: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 11/15/2023 04:38 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: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement was not met as evidence by:
Based on observations and interviews
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Facility staff agrees to have the flooring replace by 11/27/2023 by end of day 5:00 PM. Will LPA Lee will clear POC by POC visit.
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licensee did not ensure room #16 floor was in good repair. LPAs observed resident room # 16 laminate floor peeling off the concrete which is a health and safety tripping hazard risk to resident in room #16; which is a potenital health and saftey risk to residents 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: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2