<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:14:25 PM


Document Has Been Signed on 02/22/2024 06:14 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: 104DATE:
02/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Ashley SylveTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/22/24, at 7:45 AM, Licensing Program Analyst (LPA), Kimberly Viarella, made an unannounced visit to this facility to continue the case management visit from 2/15/24 regarding the resident altercation between R1 and R2 that took place on 2/13/24.  The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Ashley Sylve and a brief interview followed.

LPA completed a walkthrough of the building.  LPA observed a MedTech assisting a resident (R3) with their breakfast in a sitting area in one of the hallways in Assisted Living (AL). LPA previously spoke to R3 and asked if R3 preferred not to have their meals in the dining room, and R3 indicated that they did not care. Per the resident's LIC 602, the resident requires assistance with meals, thus the facility was in compliance.

LPA continued to Memory Care (MC) where LPA observed 3 Caregivers and 1 MedTech.  The Memory Care Director (MCD) was also present as was a representative from a hospice organization.  LPA interviewed the MCD and obtained R2's care notes, LIC 602, LIC 625 and EMAR for 12/01/23 - 2/13/24. The same information was requested for R1. 

LPA conducted interviews and reviewed records on site today but will need to return at a later date to finalize this report and discuss findings. Additional citations may be delivered at that time.

No deficiencies were observed today. A copy of this report was provided. Exit interview.


SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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 1