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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 11/21/2023
Date Signed: 11/21/2023 09:43:44 AM

Unsubstantiated


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
09/14/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230914141240
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: 103DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Tasha KeittTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident was left in soiled briefs for an extended period of time
Piles of dirty laundry observed as residents are not assisted with laundry
Resident is left to sleep on wheelchair at night due to insufficient staffing
Due to insufficient staffing residents is not provided with dinner
INVESTIGATION FINDINGS:
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On 11/21/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with interim administrator, Tasha Keitt and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 103. A brief interview with conducted with interim administrator, Tasha Keitt

Allegation: Resident was left in soiled briefs for an extended period of time
It was alleged that resident was left in soiled briefs for an extended period of time. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 7 out of 7 residents and the 7 residents reported that they have not witnessed residents in wheelchairs with soil briefs. Moreover, LPA Lee also interviewed 3 out of 3 residents who require incontinent care. The 3 residents reported they are satisfied with the incontinent care they are receiving from the facility and have no concerns about being left in soiled briefs.
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20230914141240
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: 11/21/2023
NARRATIVE
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 Allegation: Piles of dirty laundry observed as residents are not assisted with laundry

It was alleged that piles of dirty laundry were observed as residents are not assisted with laundry. This investigation consisted of records reviewed, observations and interviews with staff and residents. It was learned that the facility washer was broken and that the facility is receiving laundry services from “Love Laundry” who picks up large loads of laundry and then drops them off. During complaint visits on 09/21/2023, 10/03/2023, 10/06/2023 and 11/15/2023, LPA Lee did not observe any residents closet having piles of dirty laundry. Moreover, LPA Lee interviewed 10 out of 10 residents who stated they have no concerns with not getting their laundry done.

Allegation: resident is left to sleep on wheelchair at night due to insufficient staffing

It was alleged that residents were left to sleep in wheelchairs at night due to insufficient staffing. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 7 out of 7 residents and the 7 residents reported that they have not witnessed residents sleeping in wheelchairs. Moreover, LPA Lee also interviewed 3 out of 3 residents who require incontinent care. The 3 residents reported they don’t sleep in wheelchairs and have no concerns.

Allegation: Due to insufficient staffing residents is not provided with dinner

It was alleged that due to insufficient staffing residents are not provided with dinner. This investigation consisted of records reviewed, observations and interviews with staff and residents. It was learned that if residents don’t come to the dining room for meals, then meals are delivered to the resident’s room. LPA Lee interviewed 10 out of 10 residents and 8 out of 10 residents stated they received their dinner.


The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
09/14/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230914141240

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: 103DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Tasha KeittTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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resident bedrooms are malodorous
residents are not provided PRNs when requested
several residents do not have a working pendant
resident was not accorded with dignity and respect
INVESTIGATION FINDINGS:
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On 11/21/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with interim administrator, Tasha Keitt and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 103. A brief interview with conducted with interim administrator, Tasha Keitt

Allegation: resident bedrooms are malodorous
It was alleged that resident bedrooms are malodorous. This investigation consisted of records reviewed, observations and interviews with staff and residents. During the complaint investigation on 10/06/2023. LPA Lee observed resident (R1) room having a strong urine malodorous smell. It was learned that (R1) urinates on the carpet and that (R1) housekeeping is only scheduled once a week on Friday. When LPA Lee address this concern to administrator, Melissa Orelle on 10/06/2023, (R1) housekeeping, then was changed on 10/09/2023 to three times a week scheduled for Monday, Wednesday, and Friday. On 10/06/2023 and 11/21/2023, it was observed that (R2) room also has a strong urine malodorous smell as well. (R2) housekeeping is only scheduled for once a week on Thursday.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20230914141240
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: 11/21/2023
NARRATIVE
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 Allegation: residents are not provided with PRNs when requested

It was alleged that residents are not provided with PRNs when requested. This investigation consisted of records reviewed, observations and interviews with staff and residents. During complaint investigation on 09/21/2023 LPA Lee, LPM Camion-Lee and ombudsman, Ron observed (R2) out in front of (R2) room waiting for Med-Tech to bring (R2) PRN pain killer medication. It was learned that (R2) had pressed the call button; however, no staff came to give (R2) the PRN pain killer medication. LPA Lee observed (R2) in a wheelchair, who rolled self to the front to get PRN medications. By the end of the compliant visit, it was learned that (R2) did receive (R2) PRN medication when (R2) went to the front to ask for it.

Allegation: several residents do not have a working pendant

It was alleged that several residents do not have a working pendant. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents and 8 out of 10 residents reported that they have experienced the pendant either not working, staff does not attend to call or that it takes a long time for a staff to attend to resident’s call. Moreover, on 09/21/2023 complaint visit it was learned that resident (R3) threw (R3) call pendant away since it was not working or that one responds to the call. Licensing Program Analyst (LPA), Pang Lee Licensing Program Manager (LPM), Czarrina Camion-Lee, Ombudsman Ron Carrera, and interim administrator, Tasha Keitt checked 6 resident pendant and the 6 pendant was working: however, based call log records reviewed for the month of August and September, it was learned that there is a high volume of calls that was not responded to for more than 15 minutes. Records revealed that on 09/01/2023 (R4) pressed the pendant at 12:37 AM and the call was not cleared until 9:19 AM, a duration of 8 hours 42 minutes and 3 seconds. On 09/01/2023 (R5) pressed the pendant at 1:03 AM and the call was not cleared until 9:17 AM, a duration of 8 hours 13 minutes and 21 seconds. On 08/28/2023 (R6) pressed the pendant at 6:57 PM and the call was not cleared until 10:30 PM a duration of 3 hours 33 minutes and 6 seconds. On 08/29/2023 (R7) pressed the pendant at 2:23 AM and the call was not cleared until 8:19 AM a duration of 5 hours 56 minutes and 13 seconds. On 11/01/2023 at 3:31 PM, it was learned from administrator, Melissa Orello that the turnaround time for call response is between 9-13 minutes.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20230914141240
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: 11/21/2023
NARRATIVE
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Allegation: residents was not accorded with dignity and respect

It was alleged that residents were not accorded dignity and respect. This investigation consisted of records reviewed, observations and interviews with staff and residents. Based on complaint investigation residents were not accorded with dignity and respect due to four resident who are residing in a room that has a very strong urine malodorous smell and that resident’s room is only cleaned once a week. Moreover, 8 out of 10 residents are not receiving care, due to lack of response on pendant pressed by residents. In addition, one resident was observed waiting for PRN medication and had to rolled self to get the PRN medication in the front.

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. An exit interview was conducted with interim administrator, Tasha Keitt and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20230914141240
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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2023
Section Cited
CCR
87307(d)(2)
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87307(d)(2) Personal Accommodations and Services
The following space and safety provisions shall apply to all facilities:
The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 Interim administrator, Tasha Keitt agrees to
effective have (R2) housekeeping changed to three times a week. (R1) housekeeping was effectively changed to three times a week on 10/09/2023. Interim administrator,
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This requirement is not met as evidenced by:
Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee did not ensure (R1) and (R2) rooms are healthful from strong urine malodorus, which poses an immediate health and saftey to residents in care.
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will send LPA Lee copy of (R2) new housekeeping schudule by POC date 11/27/2023 by end of day 5:00 PM
Type A
11/27/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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 Interim administrator, Tasha Keitt agrees to have a in-service in regards to resident personal rights. Interim admin will send LPA Lee documents of training materials and sign-in sheets by POC date 11/27/2023 by end of day 5:00 PM.
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This requirement is not met as evidenced by:
Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA Lee observed four resident who are residing in a room that has a very strong urine malodorous smell and resident’s room is only cleaned once a week.
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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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20230914141240
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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87465(b)
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87465(b) Incidental Medical and Dental Care
If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication...
This requirement is not met as evidenced by:
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Facility has put in place for Pharmacy Provider Omnicare in-service schuduled for 11/16/2023, 12/04/2023. A nurse consultant is scheducled to conduct a cart audit on 12/11/2023. Facility was advised once in-service is completed documents are to be sent to LPA.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee did not ensure that (R2) recievied (R2) PRN medication when requested on 09/21/2023.
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Type B
12/01/2023
Section Cited
CCR
87303(i)(1)(B)
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87303(i)(1)(B) Maintenance and Operation
Facilities shall have signal systems which shall meet the following criteria:
All facilities licensed for 16 or more and all residential facilities...
Transmit a visual and/or auditory signal

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Facility has put in place on 11/15/2023 and conducted an audit for pendants and call lights. Facility has also updated pendant/call lights policy. In-service and updated pendant/call light policy was emailed to LPAs.
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 to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee did not ensure residents pendant calls are in a timely manner and responded tp
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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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7