342701122-3-27-2024-27-AS-KVIA-D3S29B-20240327171139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:11:45 PM

Document Has Been Signed on 03/27/2024 05:11 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 SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	SYLVE, ASHLEY		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 105	DATE:	03/27/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Ashley Sylve		TIME COMPLETED:	05:15 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 03/27/24 Licensing Program Analyst, Kimberly Viarella, made an unannounced visit to this facility to conduct a case management visit regarding a resident on resident altercation that took place on 03/23/24. 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 Vice President of Operations Laura Schutt. A brief interview followed. This LPA learned during today's case management investigation that this incident took place in the dining area of Memory Care some time around 11:00 - 11:30 AM. R2 was sitting alone at one of the tables. Staff, S1 stepped away from the dining area to distribute snacks to residents sitting on the couch in the hallway roughly 10-15 feet away. Upon returning to the dining room S1 observed R1 standing over R2 punching R2 in the back of the head repeatedly. S1 stepped between R1 and R2 and put their arms up to create a barrier. S1 and explained that R1 shouldn't do that. S1 stated that R1 had such an angry look on their face that it seemed like R1 didn't see S1 standing there. Eventually R1 stated, "F@#$ it." and walked away. Alpha One was called to transport R1 to the hospital for evaluation as he remained in an agitated state. The police were also called so that the assault could be reported. (Case Number 24-92892). R2, a hospice resident, was asked if they wanted to be sent out for evaluation but said that they were fine; they declined.The responsible parties for R1 and R2 were notified as was R2's hospice agency. LPA reviewed the LIC 602, Needs ad Services Plan, and the discharge instructions for R1. There were medication changes initiated to decrease aggression, however, a document review of observations and interviews revealed that R1 has refused medications repeatedly. R1's doctor was notified of these medication refusals. This LPA learned through reading the observation notes provided by the DFA along with information gathered from staff interviews, that staff have been redirecting and intervening to prevent

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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: 03/27/2024

NARRATIVE

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additional assaults. This LPA also learned that in order to maintain the safety of all residents in care, sometimes the rights of the other residents have been compromised in order to prevent R1 from becoming physically aggressive. For example, R1 was shouting and cussing at R2. R2 was sitting quietly and not interacting with anyone. R1 wanted R2 to move. R2 did not want to move. Staff tried to redirect R1 and were unsuccessful. Staff tried to entice R2 into leaving the room, but they were unsuccessful. In the end, staff moved R2 out of the room in order to de-escalate the situation and prevent another assault.

R1 has already been served eviction paperwork and the DFA has made calls to assist in locating an appropriate facility that has an opening.

No deficiencies were cited during this visit.

A copy of this report was provided .

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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