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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:44:57 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
12/27/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231227145427
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: 101DATE:
01/17/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley SylveTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility failed to keep safe and odor free of cigarette smoke in the building.
INVESTIGATION FINDINGS:
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On 01/17/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself, 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. The DFA informed this LPA that 2 separate meetings were conducted with residents, the first on 01/04/24 at 10:00 AM, and the second on 01/05/24 at 10:30 AM. The DFA shared the results of that meeting by providing this LPA a copy of the new smoking policy and the locations of the new designated smoking areas for the facility.

When this LPA visited this facility on 10/24/23 and 11/21/23, this LPA observed the backdoor propped open with a rock. Before closing the door, this LPA stepped outside and observed a bench up against the wall of the building. At that time there were no smokers present. During the course of this investigation this LPA interviewed both residents and staff and all 5 confirmed that they had witnessed the back door being propped open and 2 of the 5 specifically mentioned observing the smell of smoke. The standard for the preponderance of evidence has been met. Regarding the allegation, "Facility failed to keep safe and odor-
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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 3
Control Number 27-AS-20231227145427
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: 01/17/2024
NARRATIVE
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free of cigarette smoke in the building," has been SUBSTANTIATED. This deficiency has been cited on the LIC 9099 D page.

A copy of this report was provided along with APPEAL RIGHTS.

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

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20231227145427
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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a)Residents in all residential care ...shall have all ...rights:(2) To be accorded safe, healthful and... The Licensee did not ensure the above regulation as evidenced by:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee will submit the signature sheets for the inservice training regarding the new smoking policy for residents and employees. LIcensee will also provide a memo to residents and responsible parties regarding these changes. These tasks will be completed and submitted to
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Based on LPA's observations on 2 occaisions along with the 5 out of 5 interviews conducted, the facility's bck door was observed propped open allowing smoke and cold into the building which poses/posed an immediate risk to the health, safety and personal rights of residents in care.
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kimberly.viarella@dss.ca.gov by the close of business on 01/18/24.
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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: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3