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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:25:56 PM


Document Has Been Signed on 01/24/2024 04:25 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 SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 101DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Ashley Sylve and explained the purpose of the visit.

LPA Moleski reviewed eight resident files (R1-R8) and 10 staff files (S1-S10). S1, S9, and S10 did not have health screenings on file. R3's LIC 602 was dated July 22, 2022. R3 has dementia, according to the LIC 602.

LPA Moleski toured the facility with Sylve and inspected common areas, kitchen areas, bedrooms, bathrooms, and outdoor areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked room for the storage of medication.

LPA Moleski interviewed three staff members (S6, S11, S12) and three residents (R9, R10, R11).

This facility is being cited per 22 CCR Sections 87705(c)(5) and 87411(f). An exit interview was held with Sylve. Appeal rights and a copy of this report were left with Sylve.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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


Document Has Been Signed on 01/24/2024 04:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1, S9, and S10 did not receive health screenings within their first week of work, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Licensee agrees to email LPA Moleski copies of the health screenings, or, if an employee is no longer working at the facility by the POC due date, proof of resignation/termination for that employee.
vincent.moleski@dss.ca.gov

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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/24/2024 04:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R3 did not receive an annual reassessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee agrees to email LPA Moleski a copy of R3's updated LIC 602 by the POC due date, or, if updates on the status of the new LIC 602 if not otherwise available by that time.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3