342701122-2-2-2024-27-AS-KHOS-D6LQQ5-20240626122141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:35:31 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
11/17/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20231117084639

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342701122
ADMINISTRATOR:	MELISSA ORELLO		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(916) 482-7745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 102	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not answer the facility telephone.

INVESTIGATION FINDINGS:

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On 02/02/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation regarding the above allegation. LPA identified herself upon arrival and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve. A brief interview followed.

LPA conducted a walkthrough of the facility. The facility was not malodorous. In Assisted Living (AL), LPA observed 3 housekeepers, and 2 of the 3 carestaff present. LPA observed 2 residents finishing lunch in the dining room which was decorated for Valentine's Day. LPA also observed a meal cart being used to deliver lunches to the residents who did not eat in the dining room. In Memory Care (MC), LPA observed 1 housekeeper, 2 of the 3 Carestaff, and a MedTech assisting residents. LPA observed 4 residents gathered in the sitting area in the hallway and 8 more residents in the TV / dining room.

Based on 4 out of 4 interviews with staff, when individuals have called the main number, their call oftentimes

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: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231117084639

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: 02/02/2024

NARRATIVE

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did not connect with a representative, it was not transferred, and the option to leave a voicemail was not provided. This LPA learned that there were several reasons for this. At the time, there was one main line, if the concierge was on that main line, no other calls could be accepted. Sometimes the phone system would automatically forward calls to a manager's office, however not consistently. At the time of this investigation, managers were unable to access their voicemail boxes. These mailboxes were full so if calls were transferred and not picked up immediately, the caller was still unable to leave a message.

This LPA also learned during the course of this investigation that at the time of the complaint, the concierge desk was staffed until 8:00 PM and calls coming in later than that would go directly to voicemail which was not checked until the following morning at 8:00 AM.

The Designated Facility Administrator (DFA) stated that while they work on the bigger problem of their phone system, she has implemented some other strategies to improve communication. The DFA has 1 cell phone and has ordered another for the MedTech(s) on shift in Assisted Living and Memory Care so that calls may be forwarded directly to them at night when there is no one covering the concierge desk. The DFA also stated that she has ordered 2 pagers for carestaff and will continue to order 2 pagers a month until all staff are equipped with one. When phone calls come in, or call lights go off, these new tools will help staff respond more quickly. The DFA also stated that a new training is being developed for the concierges so that incoming calls will be answered and / or returned promptly, thus avoiding lengthy conversations or putting callers on hold.

According to the California Code of Regulations 87468.1(a)(14), Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.

The standard for the preponderance of evidence has been met, the allegation, "Staff do not answer the facility telephone," has been SUBSTANTIATED. This deficiency has been cited on the LIC 9099D page.

A copy of this report has been provided along with Appeal Rights.

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231117084639

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2024 Section Cited CCR 87468.1(a)(14)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities 87468.1 a) Residents... for the elderly shall have...personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls... This Licensee did not comply with the above regulation as evidenced by:	1 2 3 4 5 6 7	Designated Facility Administrator shall reach out to current phone vendor to add additional lines for incoming calls and to provide voicemail boxes for all management positions. Designated Facility Administrator shall have this completed by 2/16/24.
	8 9 10 11 12 13 14	Based on 4 out of 4 interviews, residents have not been able to receive calls or messages.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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