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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:17:40 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
12/26/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20231226132803
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: 105DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ashley SylveTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not meet resident's toileting needs
Staff did not ensure that resident was adequately fed
INVESTIGATION FINDINGS:
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On 2-16-24 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. During this investigation, LPA conducted facility observation on 1-30-24. Additional observations were conducted by LPA Viarella on 12-27-23 and 1-5-24. LPA also reviewed facility menus and conducted an interview with 5 staff members and 3 residents in care.

Allegation: Staff did not meet residents’ toileting needs. LPA conducted interviews and observations as noted above. Based on observations and interviews, it was determined that resident1 (R1) required assistance with feeding and was brought to a designated area for such service on 1-30-24. R1 then exhibited an incontinent episode as R1 was waiting approximately 30 minutes for food to arrive. Additionally, based on observations conducted on 12-27-23, it was determined that a malodorous environment existed within the memory care unit including the smell of urine. LPA’s observation also revealed a dirty adult diaper in room #33 not properly disposed of. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. {Cont.on LIC 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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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-20231226132803
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: 02/16/2024
NARRATIVE
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Allegation: Staff did not ensure that resident was adequately fed. LPA conducted interviews and observation as noted above. Based on observation and interviews, it was determined that resident1 (R1) required assistance with feeding and brought to a designated area for such service on 1-30-24. During this observation, it was revealed that R1 was at the designated location for approximately 30 minutes without food or eating assistance and exhibited spitting up as well as an incontinent episode during this wait time. Interviews conducted revealed there was no set time for when R1 would receive his food service. As a result, there is a preponderance of evidence to conclude R1 was not fed adequately. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. The licensee was previously cited for Section 87464(f)(4) on 2-16-24 and within the same investigation period for complaint # 27-AS-20231226091718.

As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231226132803
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: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2024
Section Cited
CCR
87464(f)1)
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87464(f)(1). Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee will submit a plan outlining how facility staff will efficiently meet residents' toileting needs. Plan to be submitted to LPA by POC due date.
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Based on observations, licensee did not ensure proper toileting needs were met for resident in care. This posed a potential health, safety, and resident rights risk for 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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/26/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20231226132803

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: 105DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ashley SylveTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff left residents unsupervised in the facility
Facility call system is in disrepair
INVESTIGATION FINDINGS:
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On 2-16-24 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. During this investigation, LPA conducted facility observation on 1-30-24. LPA also conducted an interview with 5 staff members and 3 residents in care on 2-7-24.

Allegation: Staff left residents unsupervised. LPA conducted facility observation and interviews as noted above. Based on interviews and observations, it was determined that adequate amounts of staff are in the facility supervising residents in care. LPA observed staff within hallways and in various resident rooms attending to resident needs. Medication technicians (Med Techs) were observed in the hallways in the presence of other residents. Resident interviews revealed staff are available to meet residents’ needs. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. An unsubstantiated finding means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. {Cont. on 9099C}

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231226132803
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: 02/16/2024
NARRATIVE
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Allegation: Facility call system is in disrepair. LPA conducted facility observation and interviews as noted above. Based on observation, it was determined that facility maintained a call system which consisted of pendants which when activated by a resident, signals the front reception desk, and identifies the corresponding room number and location for the resident requesting assistance. The receptionist will then contact caregiver to inform of such needed assistance. LPA observed this system to be functioning properly during observation on 1-30-24. Interviews with staff conducted on 2-7-24 revealed that caregivers receive notification directly on a paging device as to the location of residents in need of assistance. Interviews further revealed that the call system is functioning appropriately. LPA verified appropriate function of call system during interviews. As a result, there is not a preponderance of evidence to conclude that the facility’s call system is in disrepair at this time. Therefore, this allegation is UNSUBSTANTIATED. An unsubstantiated finding means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5