342701122-11-28-2023-27-AS-PLEE-CY287E-20231128211547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 11/09/2023
Date Signed: 11/28/2023 09:15:57 PM

Document Has Been Signed on 11/28/2023 09:15 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 SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	MELISSA ORELLO		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 106	DATE:	11/09/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sharon Wang, Josh johnson, Stephen Ratliff, Laurie McConnell and Schekesia Meadough		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance Conference (NCC) was conducted today on November 09, 2023, via Microsoft Teams with the Sacramento South Regional Office. The purpose of this NCC meeting was to discuss the high volume of deficiencies/inability of this facility to remain in substantial compliance with the regulations that have occurred within the last 18 months. Present in the meeting are: Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Pang Lee, Licensing Program Analyst (LPA) Kimberly Viarella, Ombudsman Ron Carrera. Facility representatives present include Licensee Stephen Ratliff, Licensee Sharon Wang, Licensee Josh Johnson, Vice President of Health, and Wellness, Schekesia Meadough and Director of Operations Laurie McConnell. During this virtual meeting, the Non-Compliance Conference process was explained to the Licensees. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and LIC 9111 was provided to the licensee. The facility has previously received 5 Type A citations and 10 Type B citations since 05/12/2022. Issues discussed during the Non-Compliance Conference were: · Lack of Oversight Care/Supervision/Staffing · Staff Training · Incidental Medical Care · Personal Rights of the residents · Licensee Accountability · TSP Technical Support Program · Role of Administrator/Administrator Interim · Reporting Requirements · Plan for Pest · Qualified nutritionist, dietitian, or home economist for regular consultation · Response to Call button · Staff associated to facility prior employment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 3

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
	VISIT DATE: 11/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility has stated they have implemented and will agree to do the following.
· The License shall provide the Department with an internal audit on medication for assistant living and memory care. (MARs to chart audit)
· The licensee shall provide the Department with in-service with Pharmacy provider, Omnicare, Evelyn, which will be scheduled for all staff responsible for passing medications. The licensee will provide dates by 11/17/2023 and when completed will provide the department with sign in sheets and training materials.
· The licensee shall provide the Department with in-service regarding receiving new orders and how to process orders and when completed will provide the department with sign in sheets and training materials.
· The licensee shall provide the Department with sign in sheets and training materials on Omnicare View by 11/17/2023 and when completed will provide the department with sign in sheets and training materials.
· The licensee shall provide the Department with 11/21/2023 in-service on a new medication packaging system by Onimare to help prevent medication errors.
· The facility is in the process of hiring a qualified nurse and will send hired nurse duty statement, roles and responsibilities and be added to the plan of operation.
· Vice President of Health and Wellness, Schekesia Meadough will be at the facility every week until staff are trained, and facility is structure and streamline then transition to once a month to oversight.
· The current administrator Melissa Orello is on medical leave, interim administrator is Tasha Keitt. Facility shall provide necessary documents to designate staff as the new administrator.
· The facility will ensure to hire a qualified administrator and the administrator will be present for 40 hours a week and a designated manager in the facility 7 days a week from 9:00 AM to 5:00 PM.
· Facility will ensure to train staff on Electronic Health Record (EHR). The facility switched to a new EHR System to document MARs and when completed will provide the department with sign-in sheets and training materials.
· The facility will ensure to print out physician orders and send them to all primary care doctors to get all new sign orders and have it on site and conduct a MARs to chart audit.
· Vice President of Health and Wellness, Schekesia Meadough and Director of Operations, Laurie McConnell signed up for notification that new report is posted to CCLD transparency website.
· Facility will ensure to set up and pull call log remotely and conduct an audit and address daily with staff. Facility expectation that calls lights are answered within 5-7 minutes.
· On 11/09/2023 staff will be provided with policy and procedure regarding resident call pendent. All staff will sign a policy and procedure acknowledging understanding and if a call light is over 7 mins staff will have to provide an explanation for what the reason for the longer call light. Facility will ensure to continue to educate staff and conduct audits.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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
	VISIT DATE: 11/09/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

·The licensee will ensure to send an up-to-date plan of operation regarding call lights turn around time and how often pendant are checked to ensure it’s working properly.
· Facility implanted walkie talkie for communications between staff and pendent pressed by residents.
· Licensee shall provide the Department with in-service on Pole lights, call lights and response time and when completed will provide the department with sign in sheets and training materials.
· Licensee will place a visible poster of licensee contact emails and posted for the community to address concerns.
· Facility will ensure a qualified dietitian consultation with Crandall will not at any point in time have a gap of service.
· The facility will ensure to put in place an improved process where staff can identify which residents are able to leave the facility unassisted.
· Ratio of caregivers and med-techs will be increased. Current ratios are 4:4:2 in AL and memory care and will be increased to 5:5:3 for both AL and Memory Care.
· Facility will ensure a solid plan in place to have California Pest Control service at least weekly.
· The facility will ensure a plan is in place regarding resident assessment and reassessment.
· The facility will ensure training staff on mandated reporting train and expectations.
· The licensee will submit a new application regarding management company changed to Ally.
· The facility will ensure to update LIS and LIC 500 with associated staff to the facility.
· Ensure all staff are compliant with all required training.
· The Facility Administrator will ensure the compliance plan is being followed.

During today’s meeting it was discussed that TSP engagement is available and the Regional Office will make a referral to the Unit to provide services to the facility. The Regional Office (RO) will continue to monitor the facilities’ progress. The RO will continue increased monitoring to verify compliance with issues discussed during the meeting on 11/09/2023. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3