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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 05/01/2024
Date Signed: 05/01/2024 07:32:30 PM


Document Has Been Signed on 05/01/2024 07:32 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: 103DATE:
05/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
07:45 PM
NARRATIVE
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On 05/01/24, Licensing Program Analyst  (LPM) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding complaint # 27-AS-20240325092156. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated facility Administrator (DFA), Ashley Sylve.  The DFA was in a meeting at the time.

LPA was joined by Licensing Program Manager (LPM) Stephen Richardson and the two began the visit with a walkthrough of the facility. LPA/M observed 3 housekeepers in the Assisted Living portion of the facility, 1 vacuuming and 2 servicing resident rooms, 1 caregiver in the hallway, and 1 MedTech.  There were no activities taking place at the present time.  LPA/M also visited Memory Care where they observed 12 residents in the dining room where snacks were being distributed.  LPA/M observed 1 caregiver and a MedTech in Memory Care.

LPA/M then met with the DFA to discuss the purpose of this case management visit. On 04/16/24, the LPM and the LPA interviewed the DFA about the 30 day notice that was sent to R1's Conservator.  At that time, LPM Richardson asked the DFA to provide a copy of what was sent out. DFA provided the LPM a folder with a 30 day eviction notice to R1 dated 3/15/2024 which also had exhibits A-L, along with colored post it notes with hand written reference notes from the DFA.  The LPM asked the DFA if this was the same eviction notice that was sent out to the resident and responsible party after the Department reviewed and deemed it lawful.  The DFA initially said, " I think so," to which the LPM inquired if the documentation that was presented was what was actually sent to the family.  The DFA confirmed by saying this was the eviction notice that was provided. 

LPM Richardson reviewed the 30 day notice and confirmed it was the same notice that LPA Viarella had reviewed and that she notified the facility it was lawful and okay to issue.  LPM Richardson also saw the exhibits which were observed to be the same exhibits that the DFA sent to the LPA to review to ensure it was
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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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: 05/01/2024
NARRATIVE
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lawful. The LPM asked the DFA if the exhibits were also sent out to the responsible party and DFA replied that the exhibits were also sent out as well. LPM Richardson asked for verification of how the eviction notice was issued to confirm it was the same as what was presented.  The DFA responded that they did not send the eviction notice via email, but it was sent via Certified Mail.  

On 04/12/24, the Department received a copy of the eviction letter sent to R1's conservator.  Upon reviewing the document, the LPA observed that the line, "See exhibits A-L," was not included in the version of the letter the conservator received.  In an interview with LPA Viarella on 04/23/24, the DFA stated that she did not send exhibits A-L to the conservator as previously stated in her interview with LPM Richardson on 04/16/23.  The DFA stated that she had asked the LPA if she had to include everything.  LPA Viarella responded that she could add specific examples to the body of letter itself, or the DFA could email the letter with samples as attachments.  The DFA did neither.  When the LPA asked why not, the DFA stated that, "there was a lot going on."  

During the investigation mentioned above, the Department found the allegation to be unfounded. Due to this new information (that the supporting evidence was not provided with the eviction letter) the Department amended its findings to SUBSTANTIATED on 4/03/24.

Based on the above statements the Department cited the DFA for administrator qualifications on the 809 D page.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit.

A copy of this report and Appeal Rights were provided.

Exit interview.

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

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2024 07:32 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: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2024
Section Cited
CCR
87405(d)

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87405(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
The Licensee did not comply with the above regulation as evidenced by:
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Designated Facility Administrator will rewrite eviction notice for R1 and will submit to kimberly.viarella@dss.ca.gov by the closed of business on 5/02/24.
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Based on interviews conducted and records reviewed the DFA did not provide the conservator for R1 the required specific examples which justified the eviction letter being issued to R1.
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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: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
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