342701122-4-23-2024-27-AS-KHOS-D47UQM-20240410154718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 04/03/2024
Date Signed: 04/23/2024 03:40:22 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
03/25/2024 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20240325092156

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: 103	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unlawful eviction.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/23/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to amend the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of her visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve.

Due to information obtained from an interview for a later complaint, this LPA learned that the eviction letter sent to the Power of Attorney (POA) for the resident (R1) being evicted was different in 3 ways from the version reviewed by the LPA.

LPA reviewed the eviction letter drafted by the DFA sent to Community Care Licensing on 3/15/24. The letter contained the reasons for the eviction, which were also outlined in the Admissions Agreement signed by the POA on 2/22/22. It stated, "The Community may upon thirty (30) days written notice, evict a resident if he or she fails" .... to comply with the general policies of the community. [These policies are described in this

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: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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 3

Control Number 27-AS-20240325092156

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: 04/03/2024

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

agreement and your resident handbook & House Rules.]".

Under #4 of the House Rules listed in the Admissions Agreement that was signed by the POA on 2/22/22, it stated:

4. Respect and kindness: it is important to maintain respect for one another. No resident may behave in a violent or aggressive manner (physically or verbally) towards other residents or care team members.

The DFA included Exhibits A through L to support their decision to evict R1. This LPA conducted a records review for R1 pertaining to: incident reports, the electronic medication record, and observation/care notes on file. This LPA also conducted staff interviews.

During the records review, this LPA found that a pre-appraisal was not completed for this resident by the facility. A proper pre-appraisal might have resulted in this resident finding placement in another more appropriate facility. This resident was admitted in to Assisted Living for less than a 2-week period before it was determined that R1 had behaviors better addressed in Memory Care and so R1 was moved again. This deficiency was cited in a separate case management visit on 4/23/24.

The facility used the appropriate language in its eviction letter, including an unlawful detainer statement and additional resources for alternative housing. The facility also included information regarding their appeal process and Community Care Licensing's (CCL's) complaint process.

As mentioned earlier, the eviction letter sent by the facility was different in 3 ways from the eviction letter sent to the POA.

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 and it was received by the POA on 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.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240325092156

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: 04/03/2024

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

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.

During the course of this investigation, this LPA learned that the POA had been notified and was aware of R1 physically assaulting other residents, however, the dates and details of these incidents were not included in the body of the letter and as the POA did not receive any attachments with the eviction letter, it did not contain all of the elements necessary for a legal eviction. The department therefore finds the allegation: "Unlawful eviction," to be SUBSTANTIATED and this deficiency will be cited during a case management visit later today.

No other deficiencies were observed during this 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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3