342701122-2-16-2024-27-AS-KHOS-D6LQQ4-20240626122140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 02/15/2024
Date Signed: 02/16/2024 10:54:13 AM

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: 105	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident was left in soiled clothing for an extended period of time.

INVESTIGATION FINDINGS:

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On 02/15/24, Licensing Program Analyst (LPA), Kimberly Viarella made an unannounced visit to this facility to deliver the findings for this complaint investigation. The LPA identified herself upon arrival, stated the purpose of her visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed.

LPA conducted a walkthrough of the facility. LPA observed 3 Carestaff, a housekeeper, a MedTech and the Memory Care Director (MCD) assisting residents in Memory Care (MC). LPA observed 11 residents eating lunch in the MC dining room. All appeared to be wearing clean clothing.

LPA stopped by the main dining room in Assisted Living (AL). LPA observed approximately 14 residents finishing up lunch. The residents present appeared to be wearing clean clothing. LPA chatted with 2 residents before leaving to complete the walkthrough. LPA observed 3 Carestaff and 1 Housekeeper. Common areas were all clean and free of odor.

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: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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: 02/15/2024

NARRATIVE

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With regard to the allegation: Resident was left in soiled clothing for an extended period of time.

This LPA learned through interviews that 2 out of 2 residents on hospice were not being given showers/bed baths, and their soiled clothes were not being changed in a timely fashion. Based on these interviews and observations, the above allegation was found to be SUBSTANTIATED.

According to the Code of California Regulations, Title 22, this deficiency is cited on the LIC 9099D page.

A copy of this report was 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: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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: 02/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/15/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	Managed Incontinence 87625 (b) In addition to Section 87611, General Requirements...licensee shall be responsible for the following: (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	The Designated Facility Administrator will submit a list of hospice residents and their provider by 02/15/24, and by the end of business on 02/21/24 all their care plans will be updated.
	8 9 10 11 12 13 14	The Licensee did not comply with the above regulatin as evdencd by: Based on interviews, 2 residents on hospice were not kept clean and dry.	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: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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