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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 03:47:41 PM


Document Has Been Signed on 04/23/2024 03:47 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:
02:00 PM
MET WITH:Ashley SylveTIME COMPLETED:
03:45 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).

During the course of the above investigation, this LPA learned that the DFA sent an eviction letter to the Power of Attorney for Rq1 that was different from the eviction letter reviewed by this LPA in 3 ways.

1. The date on the eviction letter should have been updated to the date it was mailed instead of the date the draft was sent to Community Care Licensing (CCL). The letter was dated 3/15/24 but it was not mailed until after 3/20/24. This meant that R1 wasn't given their full 30 days as the letter stated R1 was being evicted 30 days from the date on the letter.
2. The version of the eviction letter that CCL received contained a line at the bottom of the first paragraph of page 2 that stated, "Please see the attached Exhibits A through L to establish good cause for evicting Samuel Giudicessi." The version the POA received, did not have this line.
3. CCL also received the attached documents with Exhibits A through L. The letter that the POA received did not include those supporting documents.

The Department determined that this was an illegal eviction and the deficiency 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
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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Document Has Been Signed on 04/23/2024 03:47 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
87224

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Eviction Procedures
... Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)


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The Designated Facility Administrator stated that she would review all the eviction regulations and Provider Information Notices after which she will email an attestation of understanding to CCL at kimberly.viarella@dss.ca.gov.

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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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