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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 02/15/2024
Date Signed: 02/15/2024 06:25:15 PM


Document Has Been Signed on 02/15/2024 06:25 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: 105DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ashley SylveTIME COMPLETED:
06:30 PM
NARRATIVE
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On 02/15/24, Licensing Program Analyst (LPA) Kimberly Viarella, made an unannounced visit to this facility to conduct a case management visit. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPA met with the Ashley Sylve to discuss the incident that took place on 2/13/24 between R1 and R2. Although there were no witnesses to the altercation, R1 admitted to punching R2 in the face. A staff member (S1) stated that S1 heard shouting and banging and when S1 looked down the end of the hall, R2 was exiting R2's room and coming down the hall with blood on R2's head and face. This LPA learned through interviews that R2 was immediately provided first aid by the MedTech on duty and other staff redirected R1 into the now empty room. In the LIC 624 that was sent to Community Care Licensing on 2/13/24, R1 was upset because R2 had locked R1 out of the room they shared.

According to file reviews for both residents, both have had episodes of aggression in the past and should not have been paired as roommates. This LPA spoke to both the Memory Care Director and the Assistant Resident Director during a visit on 12/20/23 alerting them to her concerns regarding pairing these two residents as roommates. During the review of records, this LPA learned that R2 had not had a re-appraisal done for R2's change in condition when R2 was moved from the Assisted Living to Memory Care.

This LPA also learned through a records review and interviews that the facility did not document or address other incidents that occurred between these 2 residents that indicated that they were not an appropriate match as roommates. The facility did not provide the necessary care and supervision due to these two residents. According to the California Code of Regulations, Title 22, citations may be found on the LIC 809D page. Due to time constraints, this LPA will be returning at a later date to continue this case management and additional citations may be given at that time.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2024 06:25 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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87462

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Social Factors
The facility shall obtain sufficient information about each person's likes and dislikes and ...to determine if the living arrangements in the facility will be satisfactory, and to suggest the program of activities in which the individual may wish to participate.
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Designated Facility Administrator will create a new process so that when room assignments need to change due to a change of condition, a care conference with take place with all stakeholders. A draft of this process will be submitted to kimberly.viarella@dss.ca.gov by EOB 2/16/24.
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The facility did not meet the above requirement as evidenced by:
Based on interviews, records review and observations, the facility did not obtain information from or about these 2 residents to see if they would be compatible as roommates.
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Type A
02/16/2024
Section Cited
CCR87705(b)(2)

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Care of Persons with Dementia
87705(b) (2)In addition to the requirements as specified in Section 87208...(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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The Designated Facility Administrator will submit an audit for residents with behavioral incidents so that interventions may be incorporated into their care plans. This audit will be submitted to kimberly.viarella@dss.ca.gov by EOB 2/15/24.
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The facility did not meet the above requirement as evidenced by:
The facility did not intervene to address the behavioral and safety needs of these 2 residents in care as evidenced by the injury R2 received when R1 punched her in the face.
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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: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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