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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:52:39 PM


Document Has Been Signed on 02/27/2024 03:52 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:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Ashley SylveTIME COMPLETED:
04:00 PM
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On 02/27/24, Licensing Program Analyst (LPA), Kimberly Viarella, made an unannounced visit to this facility to continue the case management visits from 02/15/24 and 02/22/24 regarding the resident altercation between R1 and R2 that took place on 02/13/24.  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 Ashley Sylve and a brief interview followed.

When the LPA entered the parking lot, she observed that construction had begun for the new designated smoking area. The ground was cleared and level and there were workers in the area removing debris. The project has an anticipated completion date of 05/01/24.

LPA conducted a walkthrough of the facility. LPA observed 3 carestaff and 1 MedTech in Assisted Living. LPA did not observe any activities taking place at the time. LPA continued on to Memory Care where she spoke to the Director or Memory Care (DMC) briefly. LPA observed 1 housekeeper and 1 caretaker. DMC stated that there were 2 other agency staff on; 1 was on break and the other was assisting a resident in their room. LPA confirmed this by reviewing the schedule.

Regarding the altercation that took place on 02/13/24, this LPA learned that the previous Designated Facility Administrator, Melissa Orello, was responsible for placing R1 and R2 together as roommates. During the course of this case management investigation, this LPA learned that R1 was moved from MC to AL because the Memory Care Director at the time, (S3) stated R1 had a higher level of functioning, and their needs would be better met in AL. The resident was moved without conducting a new reappraisal. Due to incompatibility with their roommate, R1 was moved to another room in AL. When R1 moved into Legacy Oaks, the responsible party was told it was a smoke-free facility. The building was smoke-free, however, residents and staff would smoke in front of the building or just outside the rear exit. R1 was a former smoker, and smoking was a trigger for R1. R1 intentionally knocked a cigarette out of someone’s hand one day. R1
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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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
VISIT DATE: 02/27/2024
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was then moved back to MC without having the proper assessments and reappraisals conducted again.

R2 was having issues with their roommate and exhibited exit seeking behavior. R2 was also moved from AL to MC without facility staff conducting a reappraisal to address this behavior. This LPA also learned during this investigation that incident reports were not sent to Community Care Licensing about inappropriate or aggressive behaviors that would have also triggered the need for an updated LIC 602 and LIC 625. Reporting requirements were cited on 1/11/24 as part of complaint #27-AS-20231107170351 and the need for Reappraisals were cited on 11/9/2023 as the result of a case management visit.

An incident involving R2 occurred in October of 2023 which caused R2’s roommate to be swapped out and R1 was moved in to be R2’s new roommate. Both R1 and R2 had a history of aggressive behaviors. Melissa Orello was the Designated Facility Administrator at the time and did not ensure that interventions and/or supports were put into place to keep R1 and R2 in the most appropriate environment. Their physical and mental well-being, as well as their other needs and services were not met based on the findings from complaint investigation AS 202311071 70351. LPA Viarella conducted and concluded the investigation which supports the above statement.

According to the California Code of Regulations, Title 22 Division 6, this deficiency is cited on the LIC 809D page and civil penalties were assessed in the amount of $500.00. Additional penalties may be assessed at a later date.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2024 03:52 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: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
87405(h)(5)

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Administrator Qualifications and Duties (h) The administrator shall have the responsibility to: (5) Provide or ensure ...services to the residents with ... regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463.
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Designated Facility Administrator has already completed an audit for appraisals and reappraisals for Assisted Living and Memory Care. R1 and R2 have been separated into different areas of the community. Both have updated needs and assessment plans and there has been an increase in the care
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The Licensee did not ensure the above regulation was met as evidenced by:
Based on interviews and a review of records, the Designated Facility Administrator, Melissa Orello, did not ensure the provision of services to R1 and R2 with appropriate regard for their physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, and Reappraisals. This posed an immediate risk to the health, safety, and personal rights of the residents in care.
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and supervision these two individuals. A new Health and Wellness Director has been hired and she will be overseeing new processes to ensure improved resident outcomes. Other personnel changes were completed to assist with this. This POC has been cleared.

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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: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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