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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:18:35 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
10/18/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231018150755
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:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashley SylveTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility toilet support rail was not installed resulting in falls and injuries to resident.
Staff did not properly care for resident’s injury resulting in infection.
Staff did not dispense resident's medication as prescribed.
Staff did not dispose of medication no longer needed.
Staff did not safeguard resident’s personal belongings.
Staff did not respond to resident’s call for assistance.
Staff did not follow reporting requirements of unusual incidents.
INVESTIGATION FINDINGS:
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On 12/21/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. The LPA identified herself, the purpose of the visit and asked to meet with the Designated Facility Administrator, LPA met with Ashley Sylve. A brief interview followed.

The LPA took a tour of the facility with Ashley Sylve. The facility was decorated for the holiday season. Assisted Living was not malodorous. Memory Care had a strong smell of cleaning solution. LPA observed no deficiencies at this time. No organized activities were taking place at the time, but Bingo, crafts, and assistance with wrapping presents, were all scheduled for later in the day.

This LPA opened this investigation on 10/18/23, and was present at the facility on 10/24/23, 11/03/23, 11/06/23, 11/08/23, 11/09/23, 11/21/23, 12/05/23, 12/06/23, 12/11/23, , 12/12/23, 12/20/23 and 12/21/23. As part of this investigation, this LPA reviewed information gathered from 20 separate interviews
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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and as well as numerous documents provided by the facility as well as outside sources. Based on observations, interviews and a review of records, the Department came to the following conclusions.

Regarding: Facility toilet support rail was not installed resulting in falls and injuries to resident.
This LPA interviewed Francisco Ventura, the Physical Plant Director, who stated that all of the bathrooms at Legacy Oaks were equipped with grab bars.  During the course of this investigation, this LPA learned  that multiple requests had been made by the resident (R3) to have grab bars installed in their bathroom.  Staff interviews confirmed that the complainant's bathroom was not the only bathroom without grab bars. This LPA visited 6 resident rooms: 28, 57, 79, 56, 4, and 1.  LPA observed that 5 out of the 6 had grab bars, but Room 1 did not.

According to the pre-appraisal, conducted by Legacy Oaks on 07/19/23, a resident (R3) was a, "FALL RISK and was hospitalized from a fall at home," prior to being admitted into the facility.  It also stated that R3 was NOT, " Able to walk without any physical assistance (e.g. walker, crutches, other person), or able to walk with a cane. It also stated that R3 required GRAB BARS in the bathroom.

According to page 3 of the LIC 625, the Appraisal Needs and Services Plan, dated 10/26/23 and signed by Alicia Duchine, the Assistant Executive Director, at the time, R3 was "PRONE TO FALLS (FALL RISK)."

R3 was admitted to Legacy Oaks on 7/20/23. This LPA has documentation from Kaiser that R3 was seen in the Emergency Room due to falls on 08/10/23, 09/05/23, 09/11/23 and 09/24/23. 

All of these falls took place in the bathroom.  During the fall on 09/24/23, R3 caught her leg on her walker.  This resulted in a 3 cm X 10 cm laceration to the left lower leg as well as a skin tear to R3's left arm.  (Pictures were added to the document review.)

The standard for the preponderance of evidence has been met.  The Department found this allegation to be SUBSTANTIATED. According to the California Code of Regulations Title 22, this deficiency has been cited on the LIC9099 D page.

Regarding: Staff did not properly care for resident’s injury resulting in infection.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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Legacy Oaks provided this LPA a copy of an LIC 624 Unusual Incident Report for R3.  The date of the incident was listed as 09/18/23.  The report stated that R3's roommate, "Heard a loud noise and she went into the bathroom and found the resident on the ___ and the leg was bleeding.  Roommate found care staff and let her know that she was on the floor and leg was bleeding."  The report further stated that Alpha One ambulance service was called, that the responsible party was notified by phone, and that the primary care provider (PCP) was notified by FAX. The report also stated that all discharge instructions would be followed upon resident's return.  This report was dated 10/07/23 and was submitted and approved by Tasha Keitt, the Administrative Assistant at the time. 

When this LPA requested the discharge instructions for this incident, the facility could not locate any. In fact, there were no discharge instructions included in R3's file for any of R3's trips to the Emergency Room. 

During the course of this investigation, this LPA learned that the fall and injury described above did not take place on 09/18/23. R3 was not taken to the hospital on that date.  According to Kaiser's medical reports, the fall for the treatment of the leg laceration took place on 09/24/23. There were discharge instructions for this injury and they included keeping the bandage clean and dry for the first two days. The instructions also explained how to change the dressing, how to clean and dry the wound, and that the wound should be kept raised for 24-48 hours to decrease pain and swelling and to help healing.  It also stated that arrangements should be made for the doctor to remove the stitches in 10 days. 

The facility did not record or report the date of the incident accurately.  They did not ensure that they followed the discharge instructions for R3 as evidenced by the fact they did not have a copy of those instructions on file to follow.  The preponderance for the standard of evidence has been met.  The Department found this allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

Regarding: Staff did not dispense resident's medication as prescribed.

On 10/24/23, this LPA requested the Medication Administration Record (MAR) from 09/01/23 - 10/24/23 for six residents, R1 - R6. This LPA received a copy of the MAR for R3 at that time. It only included 7 days of documentation. This LPA interviewed the Assistant Executive Director (AED) regarding the lack of documentation for R3. The AED stated that per R3's LIC602, the resident was able to independently take their own medications and that was why the MAR looked incomplete. The AED went on to say that once they
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87303(e)(4)
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Maintenance and Operation 87303(e)(4)
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents. This requirement was not met as evidenced by:


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Facility has agreed to audit all bathrooms for grab bars by toilet and shower. This audit will be completed by 12/22/23 and submitted to kimberly.viarella@dss.ca.gov. Installation of any missing grab bars will be completed by 01/13/23.
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Based on interviews of both staff and residents, when R3 (repeatedly identified as a fall risk) moved into their room, there were no grab bars present. Based on observation, this LPA found another room (RM 1) without grab bars. This presented an immediate health and safety risk to residents in care.
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Type A
12/22/2023
Section Cited
CCR
87468.2(a)(1)
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Additional Per. Rights of Res. in Priv. Op. Fac. CCR 87468.2(a)(1) (a) In addition to...Section 87468.1, ...Residents ... shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Facility has agreed to ensure that it receives and follows all resident discharge instructions provided by the resident within 24 hours or returning to the facility. The Wellness Team will follow up to ensure that carestaff is following all discharge instructions.
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This requirement was not met as evidenced by:
Based on record reviews and interviews, the facility documented the wrong date of the incident and did not keep copies of the discharge instructions.
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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received the LIC 602, they stopped administering R3's medications. However, during the course of this investigation, this LPA obtained a copy of R3's LIC602 from the facility that was faxed on 07/21/23, and the MAR on record for R3 began on 08/01/23.

This LPA reviewed R3's MAR from 08/01/23 to 08/08/23.  On 11/28/23, over a month later, this LPA received the complete file for R3. In it contained another version of the MAR for R3 with entries completed for August, September, and October of 2023. This LPA only reviewed the MAR that was provided upon the initial request on 10/24/23 because it was the most accurate. Medication Logs were required to be updated at the time the medications were administered. The MAR collected on 10/24/23 showed that R3 took 11 medications on a daily basis.  For that 7 day period, 13 doses were missed or not recorded.  Based on a records review and interviews, the standard for the preponderance of evidence has been met and the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page. A case management will be conducted at a later date to address the updated MAR provided.

Regarding: Staff did not dispose of medication no longer needed.

On 12/11/23, a medication audit was performed by Omnicare of Sacramento at the request of Vice President of Health and Wellness Schekesia Meadough.  This 9 hour audit of the Medication Room and Medication Carts revealed that medications were not destroyed in accordance with facility policy, or state and federal regulations.  This LPA reviewed the results of their audit and found 7 instances where medications were not labeled when they were opened, 6 medications had expired, and there were other medications that had been discontinued, but were still in the cart and being administered. Based on this record review, this Department found this allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

Regarding: Staff did not safeguard resident’s personal belongings.

R3 stated that many of their personal belongings would go missing and the administration did nothing to resolve the situation.  Staff would sometimes be sent to assist in locating the items, however the issue of personal belongings being moved and/or stolen was not addressed.  For example, hearing aids were taken from the drawer of R3's night stand. These were never recovered. A pair of glasses were also taken and never returned or located. This LPA learned through both staff and resident interviews that there were others
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care
(a) A plan...The plan shall encourage routine medical... compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by:
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The facility shall complete an audit of all residents who self-administer to ensure that they have the required documentation and the required lock box for medication storage. This audit report shall be submitted to kimberly.viarella@dss.ca.gov. by the close of business on 12/22/23.
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Based on a review of the MARS and interviews, the facility did not dispense the resident's medication as prescribed. This posed an immediate risk to the health and safety of residents in care.
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Type A
12/22/2023
Section Cited
CCR
87218(a)
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Theft and Loss 87218(a)
(a)The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.
This requirement was not met as evidenced by:

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The facility has established a new theft and loss policy and submitted it to CCL on 12/22/23. The facility shall also create a theft and loss log at the concierge desk where it will be accessible to residents and staff. Photos of this log book will be submitted to this LPA by 12/22/23.
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Based on observation, record review, and interviews, the facility did not safeguard the residents belongings, (in this case R3's glasses and hearing aids) which posed an immediate health and safety risk to the resident 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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who agreed that R3's belongings were being taken and/or hidden by another resident, however, the administration did not mediate or investigate ways to safeguard R3's belongings.  This LPA reviewed the Resident Handbook dated 06/12/19.  It stated, "The Community is not responsible for theft, vandalism or loss of any kind to Resident's personal property. For this reason, it is strongly recommended that you have insurance in place to cover your personal property at the Community and that you contact your insurance provider to obtain a renter's insurance policy."  This is not true. According to Health and Safety Code, 1569.153(c) a theft and loss program shall be implemented by the residential care facilities for the elderly…

This LPA learned through staff and resident interviews that if a resident reported items lost or stolen, the Executive Director would follow up by submitting a report to CCL as well as the Ombudsman and police. At the time of the complaint, the Executive Director was Melissa Orello.  This LPA requested copies of these reports and none of the items R3 stated were stolen were documented or reported to the aforementioned parties. The preponderance of the evidence has been met and this Department found this allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

Regarding: Staff did not respond to resident’s call for assistance.

As part of the complaint investigation conducted on 9/14/23,  (case #27-AS-20230914141240).  LPA Pang Lee  reviewed the alert call logs for July, August, and September of 2023.  LPA Pang Lee documented 12 instances where staff did not respond to and clear the alerts from 3 hours to over 22 hours after the resident used the alert to request assistance.  This LPA performed a test on 10/24/23 during a visit to this facility.  At 12:00 PM, this LPA pulled the alert cord in the restroom across from the dining room and waited over 37 minutes for someone to come to assist.  When no one came to see what kind of assistance was needed, this LPA went to the front desk to verify that they alert was functioning properly.  This LPA could see the alert was still activated.  Based on a review of documents, interviews and personal observations, the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

Regarding: Staff did not follow reporting requirements of unusual incidents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 11 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General
(d) All personnel shall be given on the job training or have related...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by:

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Since this complaint was filed, this facility has created a Call Alert Accountability Log Sheet that is audited by Wellness Team. If staff do not respond to an alert within 7 minutes, they must complete this log explaining why. Carestaff are now assigned hallways to increase accountability and tracking.
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Based on a record review, observation, and interviews, the staff has not responded to resident call alerts. Wait times have exceeded 3 hours to 22 hours. This posed(es) an immediate health and safety risk to residents in care.
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Additional floor checks have also been instituted. Facility shall submit a sample hall assignments and a sample of the Accountability Log sheet to kimberly.viarella@dss.ca.gov.
Type A
12/22/2023
Section Cited
CCR
87465(i)(1-4)
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Incidental Medical and Dental (i) Prescription medications ... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
(1) Name of the resident.
(2) The prescription number and the name of the pharmacy.
(3) The drug name, strength and quantity destroyed.
(4) The date of destruction.
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Facility shall post medications guidelines in Medication Rooms and facility shall conduct in service with all wellness team members by 01/13/23, Signature sheets of all participants will be submitted to: kimberly.viarella@dss.ca.gov by close of business 01/13/23.
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This requirement was not met as evidenced by:
Based on a record review of the Omnicare audit along with interviews, the facility did not destroy expired medications or medications for individuals no longer in care. This posed an immediate risk to the health and safety of 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 10 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirement 87211(a)(1)
(a) Each licensee shall furnish to the licensing agency ...the following:
(1) A written report within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Since this complaint was filed, a new computerized system has been implemented. All incident reports are generated through it and are reviewed by management prior to being provided to the appropriate parties. This will ensure that all reports are submitted in a timely manner.
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This requirement was not met as evidenced by: The incident report for R3 was sent on 10/07/23 for an incident on 09/18/23. The incident. The incident actually occurred on 09/24/23, and was still in excess of the 7 day requirement. There should have been 2 additional reports sent for trips to ER for R3
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Facility shall submit fax transmittal sheets from 12/18/23 -12/22/23 and submit them to kimberly.viarella@dss.ca.com by close of business on 12/22/23.
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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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 12
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
10/18/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231018150755

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:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ashley SylveTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff gave resident another resident’s medication.
INVESTIGATION FINDINGS:
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On 12/21/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. The LPA identified herself, the purpose of the visit and asked to meet with the Designated Facility Administrator, LPA met with Ashley Sylve. A brief interview followed.

Regarding: Staff gave resident another resident’s medication.

The audit performed by Omnicare of Sacramento at the request of the Vice President of Health and Wellness included observing and evaluating 2 Medication Technicians (MedTechs) during their medication passes to residents. One of two MedTechs did accidentally attempt to provide the wrong medication, with the wrong dose, to a resident in care. It was not noted if the medication belonged to another resident, or if it was a discontinued medicine for the appropriate resident. In this complaint it was alleged that MedTech(s) were intentionally administering medications that had belonged to residents no longer at the facility (medications that had not been destroyed after residents had died or moved). This
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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LPA could not meet the standard for a preponderance of evidence and the Department found the above allegation to be UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no additional deficiencies observed or cited during today's visit.

A copy of this report and Appeal Rights were provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 12
Control Number 27-AS-20231018150755
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: 12/21/2023
NARRATIVE
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Staff did not follow reporting requirements of unusual incidents. As evidenced by the LIC 624 incident report mentioned for R3 dated 09/18/23, the incident actually occurred on 09/24/23.  The report provided to the department included a signature line was dated 10/07/23.  Regulations require that incidents of any serious injury be reported within 7 days. When this LPA requested the complete file for R3, it included incident reports dated: 08/25/23, 09/18/23, and 09/28/23. Upon further investigation, this LPA learned that there were a total of 8 instances that should have been reported to Community Care Licensing. These incidents occurred on 08/10/23, 08/16/23, 08/25/23, 08/27/23, 09/05/23, 09/11/23, 09/24/23 and 09/28/23. Based on interviews and a review of records, the Department found the above allegation to be SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

There were no additional deficiencies observed or cited during today's visit.

A copy of this report and Appeal Rights were provided.

Exit interview.



SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 12 of 12