342701122-12-20-2023-27-AS-KHOS-CZ6QRQ-20240104112419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 12/05/2023
Date Signed: 12/20/2023 01:37:11 PM

Substantiated

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
11/06/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20231106082501

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: 103	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Laurie McConnell		TIME COMPLETED:	11:00 PM

ALLEGATION(S):

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Staff took inappropriate videos, and made inappropriate comments about the residents, and posted them on social media.

INVESTIGATION FINDINGS:

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On 12/05/23, Licensing Program Analyst, (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Stephen Richardson, made an unannounced visit to this facility to deliver the findings in this complaint investigation. The LPA/LPM identified themselves, the purpose of their visit, and asked to speak to the designated facility administrator. LPA/LPM met with Laurie McConnell and a brief interview followed.

During the course of this investigation, this LPA learned the following through document review, interviews and observations.

On 11/02/23, between 9:00 PM and 9:57 PM, the Director of Memory Care (DMC), Alicia Duchine, received an anonymous text with two video clips recorded by Caregiver, Shafhia Hargrow (SH), during her shift. These clips depicted residents in Memory Care and focused on 3 individuals specifically: R1, R2 and R3. At 9:57 PM the DMC called and texted both the Designated Facility Administrator (DFA), Melissa Orello, and the Assisted Executive Director (AED), Tasha Keitt to alert them of the situation.Neither responded. The DMC took no further action that night and did not follow up with anyone else (Licensees).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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 4

Control Number 27-AS-20231106082501

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: 12/05/2023

NARRATIVE

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On 11/03/23, at 6:37 AM the AED saw the text and the video and had a conversation about next steps with DMC. The AED said she would be letting the management staff know that SH would be terminated that day. At 9:06 AM the AED called the DFA to alert her of the incident. The DFA arrived at the facility at 9:45 AM and the AED showed her the video. The DFA said that the video “did not go through” on her phone so she hadn’t seen its contents. The AED informed the DFA that she had already informed the families/responsible parties of the residents in the videos about what had occurred.

Sometime before 11:00 AM, the AED received a text from SH stating that she would not be in because “she didn’t feel comfortable with Covid” being in the building.

Between 10:00 AM and 11:00 AM, the DFA contacted the Ombudsman, the Sacramento Sheriff Department and Community Care Licensing. Community Care Licensing was told that SH would be coming in for her shift at 2:00 PM and that the Sacramento Sheriff's Department would be present at that time to arrest her and open their own investigation.

At 11:13 AM, the DFA called SH and asked if she had been recording or posting any videos of residents. SH denied it several times, however when the DFA instructed her to take the videos down, SH said she already had. The DFA asked if she would be seeing SH for her shift at 2:00 PM and SH replied, “Yes.” The DFA said good, I look forward to seeing you then. The DFA did not alert SH that she was going to be terminated.

By 1:30 PM, two Sacramento Sheriff officers, the Ombudsman, Ron Carrera, and LPA Viarella were assembled along with the AED, and the DFA in the main lobby of the building. SH’s termination papers and final paycheck were ready to be delivered as well.

Just prior to 2:00 PM an employee observed a car they thought to belong to SH enter the parking lot, circle by the police cruiser, and exit. They informed the officers of their suspicions and the police left in pursuit. SH never reported in for her shift that day. Officer D. Phillips, Sacramento Sheriff's Department, provided LPA Viarella with Police Case # 23-351600.

Community Care Licensing received a copy of the video clips as evidence. SH was clearly visible recording residents and herself in the clips. In the first part of the first clip, SH was heard to call R1 ugly. The second clip depicted R2 reclining naked from the waist down on top of their bed. The third clip was of R3 naked and

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231106082501

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: 12/05/2023

NARRATIVE

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in the shower. SH can be heard commenting on R3's clearly visible prolapsed uterus.

Community Care Licensing delivered Letters of Exclusion to Legacy Oaks of Sacramento, all of the facilities SH was associated to and, directly to SH. Legacy Oaks mailed her final paycheck her residence. The standard for the preponderance of evidence has been met. The department finds this allegation to be SUBSTANTIATED.

The deficiency was observed and cited on the LIC9099D page.

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

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231106082501

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: 12/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/15/2023 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Priv. Operated Facilities 87468.2(a)(8) (a) In addition to the rights listed in Section 87468.1 ... (8) To be free from neglect, ...involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement i not met as evidenced as by:	1 2 3 4 5 6 7	Licensee has agreed to educate and train staff regarding personal rights, privacy, Hippa, and use of cell phones during working hours. This material will also be included in the new hire packets. Licensee has agreed to complete these trainings by December 15 and will submit an outline of topics to be
	8 9 10 11 12 13 14	Based on documentation, interviews, review of media clips submitted to the Department, the Licensee did not ensure that residents' in care personal rights were not infringed upon. This posed as a potential risk to the health and safety to the residents in care.	8 9 10 11 12 13 14	covered signature sheets of participants will be submitted to kimberly.viarella@dss.ca.gov by December 15.
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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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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