342701122-9-1-2022-27-AS-KHOS-CHZMFN-20220906093437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:44:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220823152603

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 66	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Alicia Duchine		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Resident's linens are soiled

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On September 1, 2022 at 1:10 PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Assistant Administrator Alicia Duchine and explained the purpose of today's visit.

Regarding the allegation of Resident's linens are soiled, the Department found the following: based on interview, it was determined that caregivers were assisting Resident 1(R1) and getting R1 changed. During this time R1 had an emergency, and caregivers called EMS (Emergency Medical Services). The caregivers wanted to wait for the EMS to arrive before changing R1's linens, this is why EMS saw the linens soiled.

Based on interviews, it is determined that the preponderance of evidence standard is not met, therefore these allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220823152603

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	ORELLO, MELISSA		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 66	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Alicia Duchine		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility has insects

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On September 1, 2022 at 1:10 PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Assistant Administrator Alicia Duchine and explained the purpose of today's visit.

Regarding the allegation of Facility has insects, the Department found the following: based on interview, it was determined that Resident 1's (R1) room did have cockroaches. R1 as well as R1's daughter witnessed these cockroaches.

Based on interview and observation, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.
Exit interview held, Appeal Rights discussed and given, Copy of report given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220823152603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO	FACILITY NUMBER: 342701122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/08/2022 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	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. This requirement was not met by:	1 2 3 4 5 6 7	Administrator has agreed to maintain contract with terminix as well as provide LPA with copy of service bill due Date 9/8/22.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure the facility was clean/sanitary and healthful environment. The facility has a cockroach infestation in one room. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3