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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:03:45 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
11/22/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20231122103137
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 102DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Ashley SylveTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not administering resident's medication as needed
Staff are not properly trained
Staff do no ensure resident's room is clean
INVESTIGATION FINDINGS:
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On 1-10-24 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with executive director Ashley Sylve and explained the purpose of the visit. During this investigation, LPA reviewed facility file documentation including medication log sheets, facility’s medication guidelines, facility’s medication policy, facility’s staff training policy, and staff training records. Additionally, LPA conducted interviews with six staff members and three residents in care and conducted a facility observation on 11-30-23. An additional facility observation was conducted on 12-27-23 by LPA Viarella.
Allegation: Staff are not administering resident’s medication as needed. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that multiple medications were not given on various days from 11/2/23 to 11/21/23 to resident4 (R4) with primary reasons stating: “medication not available” for multiple days in a row.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 5
Control Number 27-AS-20231122103137
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: 01/10/2024
NARRATIVE
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Based on interviews, it was determined that medication was not available due to empty medication containers. A fax confirmation reviewed indicated a request was made for the medication which included Certavite-Antioxidant, Meclizine HCL, and Sertraline HCL. This fax was sent on 11-11-23, however, the medication log sheets indicate R4 received the medication on 11/11/23 as well as the following 2 days before and 1 day after this date. Additionally, resident5 (R5) was not assisted with medications between the dates of 11/23/23 and 11/29/23 with primary reason stating: “medication not available” for multiple days in a row. Based on interviews, it was determined that medication was not available due to empty medication containers. Medications include Capecitabine and Finasteride. The medication logs reviewed did not contain sufficient documentation to indicate facility's attempt to make medication available including call logs to indicate contacts with pharmacy and physicians. Facility’s medication policy states in part “Medication refills will be obtained in a timely manner”…and “Medication are never allowed to run out unless directed to by the physician.” As a result, due to medication not available, and facility staff not indicating a diligent attempt to obtain medication, the facility staff was unable to administer medication to residents as needed. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff are not properly trained. LPA conducted interviews and record reviews as noted above. LPA interviewed a total of 5 staff training records. Based on review of these records, it was revealed that 5 of 5 staff did not receive the complete number of training hours and training topics per regulatory requirements. Staff2 (S2) is a medication technician with training record indicating 5 hours of initial training within first four weeks of hire, no hospice training, no evidence of completed med tech training, and no evidence of any hands-on training to indicate completed staff initial training. Staff3 (S3) is a medication technician with training record indicating 11 hours of initial training within the first 4 weeks of hire, 10 hours of annual training, no evidence of completed med tech training, no restricted health conditions training, no hospice training, and no evidence of hands-on training to indicate completed initial staff training. Staff5 (S5) is a caregiver with training record indicating 18 hours of initial training within first 4 weeks of hire, no training on postural supports, restricted health conditions, and hospice care, and no evidence of hands-on training to indicate completed initial staff training. Staff6 (S6) is medication technician with training record indicating 18 hours of initial training within the first 4 weeks of hire, no hospice, restricted conditions, or postural support training, and no evidence of completed med tech training, and no evidence of hands-on training to indicate completed initial staff training. {Cont. on 9099C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231122103137
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: 01/10/2024
NARRATIVE
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Staff7 (S7) is a caregiver with training record indicating 3 hours of initial training within the first 4 weeks of hire, no hospice, restricted conditions, and postural support training, 2 of 12 required hours of initial dementia training, and no evidence of hands-on training to indicate completed initial training. Facility’s staff training policy states, “staff shall receive forty hours of initial training…” and “The initial medication training consists of 24 hours of initial training…” This policy also indicates hands on training to be completed as well as completion of the various training topics noted above. Additionally, interviews conducted indicated staff training was not completed in its entirety. As a result, there is a preponderance of evidence to conclude that staff did not receive the complete regulatory required training, therefore, this allegation is SUBSTANTIATED.

Allegation: Staff do not ensure resident’s room is clean. LPA conducted interviews and observations as noted above. Based on observations conducted, LPA observed housekeeping carts and housekeeping staff on duty. An observation on 12-27-23 revealed room #33 to contain a dirty adult brief on the night stand. The observation also revealed malodorous environment within the memory care unit. Interviews conducted revealed a previous presence of insects in at least 2 resident rooms, however, the facility has maintained a pest control service as documented since 1/31/23 with regular service conducted at least two times per month. Housekeeping schedule reviewed indicates a regular on-going cleaning schedule covering all facility rooms, bathrooms, hallways, and other common areas of facility. As a result, the preponderance of evidence standard is not met, and this allegation is SUBSTANTIATED.

As a result of this investigation citations are issued under Title 22 Division 6 and Health and Safety Codes as indicated on LIC 9099D. An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights and LIC 811 provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231122103137
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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on medication procedures to include but not be limited to: Documentation, working with pharmacies, and physician’s orders. Training date to be submitted to LPA by POC due date. Proof of completed staff training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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Based on record reviews and interviews, licensee did not ensure medications were administered to R4 and R5 which posed an immediate health and safety risk to residents in care.
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Licensee to submit a plan ensuring the accurate and completeness of medication log sheets. Plan to be submitted to LPA by POC due date.
Type A
01/11/2024
Section Cited
HSC
1569.625(b)
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H&S Code 1569.625(b) Staff Training… (b)This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. This requirement was not met as evidenced by:
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Licensee to ensure completed staff training. Training date to be submitted to LPA by POC due date. Proof of completed staff training to be sent to LPA no later than 2 weeks from date of citation issuance.
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Based on record reviews and interviews, licensee did not ensure completed initial staff training for S2, S3, S5, S6, and S7 which posed an immediate health and safety risk for residents in care.
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Licensee to audit staff charts to ensure completed training, and submit a plan to ensure timely completion of all staff training going forward. Plan to be submitted to LPA by POC due date.
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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231122103137
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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times…This requirement was not met as evidenced by:
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 Licensee will submit a plan outlining how staff will maintain a clean and safe living environment for residents in care. Plan to be submitted to LPA by POC due date.
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Based on observation, licensee did not ensure the cleanliness of a resident’s room environment which posed a potential health and safety risk to 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5