342701122-11-7-2022-27-AS-KHOS-CKZQ9A-20221109105800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 11/07/2022
Date Signed: 11/07/2022 03:21:33 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
10/19/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221019141507

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: 76	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Alicia Duchine		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Staff are not meeting resident's bathroom needs resulting in resident's left soiled for an extended period of time
-Staff are not administering resident's medications as prescribed
-Staff threatens resident's in care
-Staff do not keep resident's rooms clean and sanitized

INVESTIGATION FINDINGS:

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On 11/7/22 at 1:45 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 Staff are not meeting resident's bathroom needs resulting in resident's left soiled for an extended period of time, the Department found the following; based on interview, record review and observation, it was determined that resident's are getting 2 hour checks and not being left soiled.

Regarding the allegation of Staff are not administering resident's medications as prescribed, the Department found the following; based on interview and record review, it was determined that resident MAR was completed, and resident was receiving the proper medication.

Report continued on LIC9099C...

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: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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 4

Control Number 27-AS-20221019141507

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
	VISIT DATE: 11/07/2022

NARRATIVE

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Regarding the allegation of Staff threatens resident's in care, the Department found the following; based on interview it was determined that multiple residents stated that staff have never threatened them or they do not feel threatened by staff.

Regarding the allegation of Staff do not keep resident's rooms clean and sanitized, the Department found the following; based on interview and observation, it was determined resident rooms are being cleaned and sanitized. LPA observed multiple rooms and each room was cleaned at the time and there was no foul odor.

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.

Exit interview conducted. A copy of this report was left upon exit.

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: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/19/2022 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221019141507

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: 76	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Alicia Duchine		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Staff do not empty resident's catheters

INVESTIGATION FINDINGS:

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On 11/7/22 at 1:45 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 Staff do not empty resident's catheters, the Department found the following; based on interview and observation, it was determined that Resident 1 (R1's) catheter bag was not emptied. The bag was pretty much full during the PM shift and when the AM shift came in they saw the bag was completely full. This is when the bag was emptied.

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: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20221019141507

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: 11/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/08/2022 Section Cited CCR 87623(b)(2)(A)	1 2 3 4 5 6 7	87623 Indwelling Urinary Catheter (b) In addition to Section 87611...the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional...(A) The bag may be emptied by facility staff who receive instruction from an appropriately skilled professional. This requirement was not as evidence by:	1 2 3 4 5 6 7	Administrator has agreed to conduct an in-service training on emptying catheter bags. POC due 11/8/22
	8 9 10 11 12 13 14	Based on observation, the licensee did not ensure the Resident 1 (R1's) catheter bag was emptied in a timely manner. This poses an immediate 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: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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