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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 01/11/2024
Date Signed: 01/11/2024 06:00:39 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
11/07/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231107170351
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:
01/11/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to report incidents to Community Care Licensing.
Facility did not send residents out for medical evaluation and treatment.
Facility failed to supervise residents in care.
INVESTIGATION FINDINGS:
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On 01/11/24 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 upon arrival, stated the purpose of her visit, and asked to meet with the Designated Facility Administrator. LPA met with Ashley Sylve. A brief interview followed.

This LPA took a tour of the facility and found that Memory Care was malodorous throughout. The Assisted Living portion of the facility was not malodorous. This LPA did not observe any activities taking place during today’s visit.

Regarding the allegation: Facility failed to report incidents to Community Care Licensing
An SOC341 was received by Community Care Licensing on 11/03/23 describing an incident that may have occurred between R1 and R2. R2 was found bruised with a cord wrapped around R2's neck. Based on 7 interviews conducted, this LPA was able to confirm that R2 was found with bruises on R2's head and arms
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: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
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-20231107170351
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: 01/11/2024
NARRATIVE
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on the morning of 10/25/23 or 10/26/23. One of the interviewees confirmed that they saw the oxygen cord wrapped around R2's neck. It could not be confirmed whether this occurred through an altercation of some kind, or if R2 obtained the bruises through a fall and accidentally wrapped the cord around their own neck. There were no witnesses. This incident was not reported to CCL. R2 was moved to a different room. When interviewed, the Director of Memory Care (DMC) stated that she had documented the incident, however, when this LPA and the DMC went into the computer system used to track and store this information, there was no report found.


The preponderance of the evidence has been met, the allegation that the, "Facility failed to report incidents to Community Care Licensing," has been SUBSTANTIATED. A citation for this deficiency may be found on the LIC 9099D page.

Regarding the allegation: Facility did not send residents out for medical evaluation and treatment.

Based on a review of documents and interviews with the DMC and the Community Relations Director (CRD) this LPA learned that R1's behaviors had changed over time. On 03/22/23, R1 moved into the Assisted Living portion of the facility, however, over time R1 exhibited behavioral changes and did not get along with other residents. R1's desire to elope the facility also increased, as evidenced when R1 packed all of their belongings and called for an Uber. This constituted a change in behavior and R1 should have been sent out for an evaluation and an updated LIC602 prior to being moved into Memory Care. This was not done.

R1 was moved into Memory Care on 07/24/23. On 11/05/23, CCL received an LIC 624 that stated the following. On November 1, 2023, at approximately 9:00 AM, R1 told staff members that roommate, R3, was not going to be around much longer. Staff went into their shared room to have a conversation with R1 and they found numerous sharp objects in the room. R1’s responsible party (RP) was notified and when RP brought R1 back from lunch the room was searched again, and additional objects were found. LPA was told during interviews that these objects included 3 or 4 screwdrivers and a knife-like letter opener. These objects, which were a danger to residents in care, were hidden under pillows and wrapped in clothes. This was an escalation of R1’s behavior and a change of condition, R1 should have been sent out for a medical evaluation. This was not done.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231107170351
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: 01/11/2024
NARRATIVE
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The preponderance of the evidence has been met, the allegation that the, “Facility did not send residents out for medical evaluation and treatment,” has been SUBSTANTIATED. A citation for this deficiency may be found on the LIC 9099D page.

Regarding the allegation: Facility failed to supervise residents in care.

Legacy Oaks reported that on 11/01/23, they found approximately 7 sharp objects including screwdrivers and a letter opener in R1’s room. This was evidence of a lack of supervision. Those objects should not have been available to R1 as they posed an immediate risk to the health, safety, and personal rights of residents in care. On 12/27/23, this LPA observed an open door in Memory Care. LPA knocked on the open door, identified herself and entered the room. LPA observed toxic personal care items. These items included: an approximately 16-ounce bottle of Purell hand sanitizer, a tube of oatmeal daily moisturizing lotion, and Pantene Shampoo. LPA took pictures for documentation purposes. LPA reviewed the LIC 602s for both residents in that room. Both residents were not at risk to have personal care items, however, the door was open to this room, so the items were available to any resident who entered, thus the health and safety of residents in care was put at risk. The LIC 602 for the other resident was dated 10/29/22 and was outdated; they may no-longer be safe to have access to personal care items. Per California Code of Regulations, Title 22, every resident with a dementia diagnosis is required to have their LIC 602 updated annually or whenever there is a change in condition. This was also evidence of a lack of supervision and care. These additional deficiencies have been documented and will be cited during a case management visit on 1/11/24.

Based on information gathered through interviews, a review of records, and personal observations, the preponderance of the evidence has been met and this allegation had been SUBSTANTIATED. A citation for this deficiency may be found on the LIC 9099D 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: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231107170351
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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements (a) Each licensee shall furnish to...the following:
(1) A written report shall be submitted... licensing agency...(D) Any incident which threatens the welfare, safety or health... The facility was not in compliance with the above regulation as evidenced by:
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Reporting Requirements and Documentation Requirements Training for ALL departments has already begun. Trainings were conducted on 01/09/24 and 01/10/24. Additional training is scheduled for the All Staff meeting on 01/17/24. Designated Facility
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Based upon a record review and 7 interviews conducted by this LPA, the facility did not notify CCL that R2 was found with bruises on R2's head and arms. This posed an immediate threat to the health, safety and personal rights of residents in care.
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Administrator shall submit training materials and signature sheets to kimberly.viarellas@dss.ca.gov by COB 01/12/24.
Type A
01/12/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental... by compliance with the following:
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

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The Designated Facility Administrator will provide an audit of all LIC 602s for residents with a dementia care diagnosis, and will provide this to CCL by the close of business tomorrow by submitting to: kimberly.viarella@dss.ca.gov.
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The facility was not in compliance with the above regulation as evidenced by:
Based on a review of records (LIC602) R1 experienced a change in condition on 2 occasions and should have been sent out for a medical evaluation. This was not done. This posed an immediate threat to the health, safety and personal rights of 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231107170351
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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87705(f)(1)
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Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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The facility has agreed to perform room sweeps of memory care looking for prohibited items. Documentation will be submitted to kimberly.viarella@dss.ca.gov. by the close of business on 01/12/24.
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The facility did not comply with the above regulation as evidenced by R1 hiding approximately 7 sharp objects including screwdrivers and knife-like letter openeners in R1's room. This posed an immediate threat to the health, safety and personal rights of 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5