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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:33:32 PM


Document Has Been Signed on 04/23/2024 03:33 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 SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 104DATE:
04/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
12:15 PM
NARRATIVE
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On 04/23/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit with regard to the deficiency observed during the complaint investigation # 27-AS-20240325092156 reported on 03/25/24. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). The LPA began her visit with a tour of the facility.

LPA observed 5 Carestaff and 2 MedTechs on the Assisted Living side of the facility, along with 2 housekeepers. The repair on the hot water pipe in one of the hallways was completed and the LPA saw that the area had been cemented over and was surrounded by caution tape. LPA also observed that the warped flooring in the break room had been replaced. This LPA checked both of the medication carts during her tour to ensure that they were locked and in compliance. When the LPA entered the large activity room at the front of the facility, she observed a resident cleaning up after a morning group craft activity.

In Memory Care, the LPA observed 3 Carestaff and 1 MedTech. 1 staff member was assisting residents in the dining area with morning snacks, another was helping a resident change, and the third was doing room checks. Podiatry was on site today and many residents were scheduled for pedicures. Bingo was the next activity on the schedule for the day.

LPA noted new large calendar posters hanging in Memory Care and outside of the Dining Room in Assisted Living that listed all of the scheduled activities for residents.

LPA returned to meet with the DFA to address the reason for today's visit. During the complaint investigation mentioned above, the LPA conducted a records review. The LPA learned that a pre-appraisal was not conducted prior to the resident (R1) mentioned in the complaint. R1 moved into Assisted Living on 12/12/22 but lived there for less than a 2-week period before it was determined that R1 had behaviors better
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 04/23/2024
NARRATIVE
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addressed in Memory Care and so R1 was moved again.

The LPA conducted an interview with the DFA on 04/03/24. The DFA stated that the Designated Facility Administrator at the time of R1's application, did not ensure that a pre-appraisal was completed.

According the California Code of Regulations, Title 22, Chapter 8, this violation was cited on the LIC 809D page.

No other deficiencies were observed or cited during today's visit.

Due to technical difficulties, this LPA was unable to provide a printed copy of this report at the end of the visit, however a handwritten report was left on site to document this case management and a copy of this report and the APPEAL RIGHTS will be emailed within 24 hours.

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

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/23/2024 03:33 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87457(a)

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(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions.
The Licensee did not comply with the above regulation as evidenced by:
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Designated Facility Administrator stated that she would conduct an audit of pre-appraisals and appraisals in Assisted Living (Memory Care has already been completed). This will be completed and submitted by close of business on 4/24/24 to kimberly.viarella@dss.ca.gov.
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Based on a review of records and an interview with the DFA on 04/03/24, that a pre-appraisal was not conducted for R1. This posed(s) an immediate risk 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: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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