<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 05/03/2024
Date Signed: 05/03/2024 05:41:28 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
12/01/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231201090841
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 104DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Ashley SylveTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not properly maintain centrally stored medications.
Facility staff did not meet resident's showering needs.
Facility staff did not serve appropriate meals.
Facility staff did not dispense medications to resident as prescribed.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/03/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findins for the complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed.

Regarding the allegation: Facility staff did not properly maintain centrally stored medications.
Based on a records review and interviews with the DFA, the facility was not able to produce any evidence of of a Centrally Stored Medication Log for the time period of 10/23/23 through 12/23/23. The standard for the preponderance of evidence has been met, the Department finds the above allegation SUBSTANTIATED. The citation for this deficiency may be found on the LIC 9099 D page.

Regarding the allegation: Facility staff did not meet resident's showering needs.
This LPA conducted a record review of shower logs for 3 residents, R2, R5, R10 for October through

• R2 missed 11 of their 18 scheduled showers and received 2 that were not on scheduled days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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 8
Control Number 27-AS-20231201090841
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: 05/03/2024
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
December of 2023.

· R2 missed 11 of their 18 scheduled showers and received 2 that were not on scheduled days.
· R5 received 2 out of their 9 scheduled showers with an additional 2 showers occurring on 10/9/23 and 11/24/23.
· R10 had 6 out of the 20 scheduled showers, with one additional shower on 11/05/23 and 1 refusal on 10/30/23.

The preponderance for the standard of evidence has been met, the Department finds the above allegation SUBSTANTIATED. The citation for this deficiency may be found on the LIC 9099 D page.

Regarding the allegation: Facility staff did not serve appropriate meals.

LPA toured the dining room and kitchen on 12/11/23. LPA spoke to 3 residents, R2, R3 and R4 about the meals. 3 out of 3 residents said that there was too much high fat and salty food on the menu. LPA asked for examples and they mentioned pork chops, sausages with peppers and onions. R2 said that they serve a lot of things that are hard for older people to digest. “A lot of us have issues with constipation, weight or diabetes,” R2 said, "We can't digest these things." LPA then met with the Culinary Director who stated that he had no background in nutrition but that they had a consulting agency that provided access to nutritional menus. LPA asked if this agency specialized in meals for assisted living facilities or hospitals, and he stated that he thought they focused on hospitals. LPA stated that this population had specific requirements that needed to be addressed. The LPA explained that she was investigating a complaint that the food being served was not appropriate. The culinary directory stated he would look into it to see how things could be improved.

On 12/12/23 the LPA also had a conversation with the Vice President of Health and Wellness (VPHW), regarding the facility menu. She stated that the menus needed improvement and they were exploring other vendors. Based on a review of records and interviews, the preponderance of the evidence has been met and the Department finds this allegation to be SUBSTANTIATED for the time period in question. The citation is listed on the LIC 9099 D page.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20231201090841
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: 05/03/2024
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
Since then, the administration has made changes to the staff and the menus. This LPA has observed improvement and residents R2 and R3 were re-interviewed today, 5/1/24 and both stated that the food food offerings have improved since they brought on a new Culinary Director.

Regarding the allegation: Facility staff did not dispense medications to resident as prescribed.

This allegation was already substantiated and addressed on complaint control #27-AS-20231122103137.

According to the California Code of Regulations, Title 22, not other deficiencies were observed or cited during today's visit. A copy of this report was provided along with APPEAL Rights.

Exit interview.

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

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20231201090841
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: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2024
Section Cited
CCR
87465(a)(6)
1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed...with the following: (6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility.
The facility did not comply with the above regulation as evdenced by:
1
2
3
4
5
6
7
Designated Facility Administrator now has CSMR in binders, and is proceeding training to ensure proceedures are followed and the Health and wellness Director is overseeing the process.

This POC hasd been cleared.
8
9
10
11
12
13
14
Based on observation, interview and record revew, the facility did not have a Centrally Stored Medication Log for the time period of 10/23/23 through 12/23/23. This posed an immediate risk to the health, safety, and/or personal rights of residents in care.
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20231201090841
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: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
Basic Services 87464(F)(4)
(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated...bathing...
The facility did not comply with the above regulation as evidenced by:


1
2
3
4
5
6
7
The Designated Facility Administrator stated that she has imlemented a new shower schedule along with increasing staff to assist with showers. A new resident signature sheet has been impleented if a shower is refused and the Health and Wellness Director now oversees the processes.
8
9
10
11
12
13
14
Based on interview and record review, R2, R5, and R10 did not receive their scheduled showers 11/18, 2/9 and 6/20 respectively. This poses/ed a potential health, safety and/or personal rights risk to the residents in care.
8
9
10
11
12
13
14
This POC has been cleared.
Type B
05/24/2024
Section Cited
CCR
87555(b)(5)
1
2
3
4
5
6
7
General Food Service Requirements
(b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods consideration for food habits of residents. The facility did not comply with the above regulation as evidenced by:

1
2
3
4
5
6
7
The Designated Facility Administrator has hired a new Culinary Director with experience in Assisted Living. He has introduced a new diabetic menu as well as an "Anytime" menu.

DFA has also had the Dietary consultant conduct a quarterly review.
8
9
10
11
12
13
14
Based on interviews with the residents and the Vice President of Health and Wellness, during the time period of this complaint the facility did not serve appropriate meals. This posed a potential health, safety and/or personal rights risk to residents in care.
8
9
10
11
12
13
14
This POC has been cleared.
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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
12/01/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231201090841

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 104DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Ashley SylveTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide activities for residents.
Facility staff did not ensure resident had clean linens.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/03/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findins for the complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed.

Regarding the allegation: Facility staff did not provide activities for residents.
During the time perid in question, this LPA learned that the Activities Director was out and the amount and variety of activities decreased, however, the facility held the following activities: Birthday Celebration for November Birthdays, Cermaics every Tuesday, Bingo 3 times a week in both Assisted Living (AL) and Memory Care (MC), Crafting Christmas Decorations: Bells, Painting Decorations, and residents made pumpkins out of wine corks. There were also group exercises every morning from 8:45 - 9:30 AM and jelwlery making twice a week from 10:00 -11:00 AM. The facility did not keep records of how many residents attended these events, but they were offered. The standard for the preponderance of evidence has not been
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20231201090841
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: 05/03/2024
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
met; the Department finds the above allegation to be UNSUBSTANTIATED.

Regarding the allegation: Facility staff did not ensure resident had clean linens.

Based on observations and interviews conducted by this LPA on 12/12/23, 5 out of 5 residents agreed that there linens were clean. On 03/37/24, this LPA also inspected 5 resident rooms and did not observe soiled or dirty linens. The standard for the preponderance of evidence has not been met: the Department finds the above allegation to be UNSUBSTANTIATED.

A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No other deficiencies were observed or cited during today's visit. A copy of this report was provided, along with Appeal Rights.

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

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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
12/01/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231201090841

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:MELISSA ORELLOFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 104DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Ashley SylveTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unqualified staff administered insulin to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/03/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings for the complaint investigation into the above allegations. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed.

Regarding the above allegation: Unqualified staff administered insulin to resident.

The reporting party withdrew the allegation. The Department therefore finds the allegation to be UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 8