342701122-5-13-2024-27-AS-KVIA-D58QT9-20240513122645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 05/13/2024
Date Signed: 05/13/2024 12:26:58 PM

Document Has Been Signed on 05/13/2024 12:26 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 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:	05/13/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	12:23 PM

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	On 5/13/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility to discuss an incident reported on 05/08/24. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA), LPA met with Ashley Sylve and a brief interview followed prior to the LPA taking a walkthrough of the facility. The walkthrough began in Assisted Living. LPA observed 1 person sitting at the craft table in the activities area, and 2 residents watching TV. LPA also observed 2 residents in the sitting area of the main lobby. The Activities Assistant was seen by the LPA walking towards the activity room when the LPA was on the way to Memory Care. While passing the laundry room, LPA checked to ensure the door was locked and all chemicals were inaccessible to residents in care. LPA was able to enter the laundry room and was greeted by staff who stated they always lock the door upon exiting. LPA continued on to Memory Care. Memory Care was not malodorous. LPA observed 7 residents having snacks in the dining/activities room. Two residents were sitting on the sofa in the hallway. LPA observed 2 staff and 1 MedTech assisting residents. LPA was approached by a resident who complained of stomach pain. LPA and MedTech listened to the resident's concerns and checked the Electronic Medical Record to see if there was a PRN that could be administered. All medications had been given that morning. As this was a change in condition for this resident, the responsible party was contacted and the MedTech documented the change so it might be reviewed by the Health and Wellness Director. The MedTech also went to the kitchen to see if she could find something that would calm the resident's stomach. LPA left Memory Care and observed 1 housekeeper vacuuming and 1 care staff walking down the hall. As stated above, and incident report was faxed to Community Care Licensing (CCL) regarding a situation that was reported on 05/08/24 where a caregiver (S1) who agreed to run an errand for a resident, (R1). R1 did not have any cash, so they gave S1 their debit card. S1 used the R1's debit card to make a personal purchase .

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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 2

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: 05/13/2024

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

LPA interviewed the DFA. The DFA stated that this incident took place sometime in 2023. Neither R1 nor S1 could provide exact dates. The Sheriff's Department, the Ombudsman, and the responsible party for R1 were notified along with CCL. A representative from the Sheriff's Department arrived and interviewed R1 who stated they did not want to press charges (Report # 24-146259).

The DFA took written statements from S1 who admitted to having used the resident's debit for personal purchases. DFA also took a written statement from S2 Both statements were provided to CCL. The DFA took disciplinary action and S1 received a written FINAL warning. S1 was also required to complete mandatory training for elder abuse. The warning signed by S1 stated that, "Any further violations will result in further disciplinary actions up to termination."

Due to time constraints, this LPA will be returning to investigate this incident further and additional actions may be taken at a later date.

According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided. Exit interview

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2