342701122-2-21-2024-27-AS-KHOS-D6LQQ3-20240626122140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 02/21/2024
Date Signed: 02/21/2024 05:23:35 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: 104	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide adequate supervision to the residents.

INVESTIGATION FINDINGS:

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

On 02/21/24, Licensing Program Analyst (LPA), Kimberly Viarella, made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself, the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve.

On 2/16/24 this LPA interviewed the DFA regarding the above allegation. The LPA stated that part of the reporting party's complaint indicated that upon visiting a resident in Assisted Living one evening, they could not locate any staff on duty. They activated the call alert in the resident's room, but no one responded. During the LPA's meeting with the DFA, the DFA stated that back at the time of this complaint in November of 2023, there was not a consistent staffing ratio and the shifts were AM Shift: 6:00 AM -2:00 PM, PM Shift: 2:00 PM - 10:00 PM, NOC Shift: 10:00 PM - 6:00 AM. Upon a records review for September, October and November, this LPA found staff levels varied and the facility had a limited number of trained MedTechs to work the floor. This LPA observed the Assistant Executive Director and the Memory Care Director taking over the administration of medications because the facility did not have

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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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-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: 02/21/2024

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

enough trained staff qualified to staff the scheduled work week. The DFA stated that shortly after she assumed the position as Executive Director on 12/12/23, she determined that the number of complaints indicated that the needs of the residents in care were not being met. The DFA purchased walkie-talkies for carestaff in order to improve communication in order to respond to residents' needs. Cell phones were also purchased for MedTechs in AL and MC with the intention of having calls routed to them that came in after the concierge staff left for the day. The DFA stated that once the concierge staff leaves for the day, a visitor might not be able to immediately locate staff as they might be in resident rooms assisting them with direct care.

The DFA also altered the time frame for the shifts to include time for the communication of important information between shifts. All shifts were altered to include a 30 minute overlap to accommodate this exchange of information. In addition, the new DFA increased staffing to the following: Memory Care both for AM and PM shifts: 1 MedTech, 3 Caregivers, 1,1:1 for behavioral interventions, NOC: 1 Caregiver, and 1 shared MedTech with AL with an increase to a designated MedTech in mid-March. In Assisted living AM and PM Shifts: 2 MedTechs, 3 Caregivers and 1, 1:1 for behavioral interventions. NOC Shifts: 1 MedTech and 3 Caregivers. The DFA supplemented any open shifts with agency staff.

Based on this interview and a review of the scheduling records for October, November, and December of 2023 compared to the current staffing ratios, the above allegation, "Staff did not provide adequate supervision to the residents." has been SUBSTANTIATED. According to the California Code of Regulations, Division 6, Chapter 8, the deficiency was cited on the LIC 9099D page. Since staffing was increased to resolve the concerns in this complaint, the plan of correction has been satisfied and cleared.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 02/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more...personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings,	1 2 3 4 5 6 7	The Designated Facility Administrator (DFA) changed the schedule shifts to improve communication amongst staff and increased staffing throughout the facility, supplementing with agency staff when needed to maintain the posted schedule. In addtion, the DFA purchased
	8 9 10 11 12 13 14	The facility did not comply with the regulation above as evidenced by: Based on the interview with the Administrator, the number of complaints indicated that the needs of the residents in care were not being met. This posed an immediate risk to the health, safety, and personal rights of the residents in care.	8 9 10 11 12 13 14	walkie-talkies to increase communication. Cell phones were also purchased for a Med Tech on duty in Assisted Living as well as in Memory Care so that when calls came in after the Concierge left for the day, staff could be notified and located throughout the building. This POC has been cleared.
	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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3