342701122-3-20-2024-27-AS-KHOS-D3PPKB-20240325112252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:35:06 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
12/29/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20231229143029

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:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff violated residents' personal rights by not allowing them to get medical assistance.

INVESTIGATION FINDINGS:

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On 3/20/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation into the above allegation. 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.

Regarding the allegation: Staff violated residents' personal rights by not allowing them to get medical assistance.

This LPA conducted a review of the Electronic Medication Records and care notes/observations for R2. R2's rash on R2's arms and body was first documented on 11/08/23. R2 was sent to the hospital and came back with 2 prescriptions later the same day. These new medications were documented on 11/09/23. A diagnosis was not listed in the electronic record reviewed. The next entry was documented on 12/29/23 and stated that R2's

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231229143029

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: 03/20/2024

NARRATIVE

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rash was observed on their "torso, bilateral shoulders, bilateral arms, and bilateral legs." It also stated that a message was left for PCP" to request an urgent referral for Dermatology consult."

During the course of this investigation, this LPA learned through interviews with R2 and 3 staff members, S1, S2, and S6, that on 12/27/23, R2 had a bloody rash on R2's body and that R2 requested transportation to the hospital. R2 had a conversation with the Health and Wellness Director, (HWD). The HWD at that time, (a new HWD took over the role in 2/21/24) attempted to secure an appointment for R2 with a Dermatologist, but did not send the resident out as R2 requested.

R2 stated to the HWD and to staff in the lobby that they did not want to wait for a scheduled appointment, that they were itchy and bleeding. R2 wanted to be seen that day as the rash was uncomfortable. The HWD went into their office to try and schedule an appointment with Dermatology. At that point, R2 used the phone at the front desk to call 911 so that R2 could obtain transportation to the hospital. R2 waited in the lobby of the facility until the ambulance arrived.

The HWD met with the emergency response team and explained that the HWD was attempting to schedule an appointment for R2. The HWD stated that the ER would not be able to diagnose the problem and that it, "would be a waste of time to go there." R2 was not transported to the hospital and did not get relief from the itchy bloody rash that day. R2's request for transport, the arrival and dismissal of the ambulance was not documented in the observation/care notes.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231229143029

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: 03/20/2024

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 26 27 28 29 30 31 32	Based on information gathered through interviews, combined with a review of records, the department found the above allegation to be SUBSTANTIATED. According to the Code of California Regulations, Title 22, deficiencies were cited on the LIC 9099D page. A copy of this report was provided along with Appeal Rights. Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231229143029

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: 03/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/21/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Med & Dental 87465(a)(1) (a) A plan for incidental and medical care ... provide for assistance in obtaining such care, 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.	1 2 3 4 5 6 7	Designated Facility Administrator stated that the Health and Wellness Director at that time was suspended and terminated for not sending R2 out for medical treatment as R2 requested. Emergency response training for a change of condition was also provided to staff on
	8 9 10 11 12 13 14	The facility did not meet the requirements of the above regulation as evidenced by: Based on 4 interviews, and a review of records, the Health and Wellness Director did not assist R2 in obtaining transportation to the hospital as R2 requested.	8 9 10 11 12 13 14	1/9/24 with Management and 1/17/24 with staff. Signature sheets were provided to LPA as proof of correction. 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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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