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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 09/25/2024
Date Signed: 09/27/2024 01:41:44 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
05/09/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240509155142
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 102DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Sylve TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not ensure resident's room is clean and sanitized in a timely manner.
Staff do not ensure resident(s) are provided a healthy and safe environment.
INVESTIGATION FINDINGS:
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On 09/25/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of her visit and asked to speak with the Designated Facility Administrator / Executive Director (ED) Ashley Sylve. LPA met with the ED and a brief interview followed.

LPA conducted a walkthrough of the facility. LPA observed 12 residents participating in morning exercises led by the Activities Assistant in the front room of assisted living. LPA later toured memory care and observed 8 residents finishing up their meals and watching House on TV. There were 7 other residents in the common area along the hall interacting with one another and staff. LPA counted 4 staff present.

Regarding: "Staff do not ensure resident's room is clean and sanitized in a timely manner." LPA Viarella inspected the resident's (R1/R3's) room on 5/14/24 and found it to be clean and odor free. LPA
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 6
Control Number 27-AS-20240509155142
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: 09/25/2024
NARRATIVE
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LPA requested a copy of the housekeeping schedule and found that according to the schedule, R1/R3's room was scheduled to be cleaned twice a week on Tuesdays and Saturdays with laundry being done for both roommates on Thursdays. Upon a review of checklists completed by housekeepers assigned to clean their room, LPA observed the following:
For the week of:
03/31/24, it was cleaned on 04/05/24
04/07/24, it was cleaned it 04/07/24 and 04/12/24 and 04/13/24 (Saturday and Sunday).
04/14/24, it was cleaned on 04/19/24 and 4/20/24 (Saturday and Sunday).
04/28/24, there is no record of the room being cleaned.
05/05/24, it was cleaned on 05/07/24.
05/12/24, it was cleaned on 05/15/24.
05/19/24, it was cleaned on 05/21/24.
05/26/24, it was cleaned on 05/28/24.
06/02/24, it was cleaned on 06/04/24.
06/09/24, it was cleaned on 06/19/24.
06/23/24, it was cleaned on 06/25/24.

The dates that were bolded indicate that the room was cleaned according to the cleaning schedule.  Even though the schedule from housekeeping indicated that the room was cleaned twice a week, that was not the case in 9 out of 10 of the weeks above.

The standard for the preponderance of evidence has been met and the above allegation, "Staff do not ensure resident's room is clean and sanitized in a timely manner," has been SUBSTANTIATED.  According to the California Code of Regulations, Title 22, this deficiency has been cited on the LIC 9099D page. 

Regarding: "Staff do not ensure resident(s) are provided a healthy and safe environment."

In addition to the housekeeping logs, this LPA conducted interviews. Staff, S3, S4 and S6 all confirmed that R3 has removed their adult brief, filled with feces, and either dropped or thrown it on the floor or against the wall in R1/R3's room.  Carestaff have had to repeatedly clean up the mess and this sometimes could not be done immediately as they were "assisting other residents."
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240509155142
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: 09/25/2024
NARRATIVE
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During the course of this investigation, this LPA reviewed the records of visits conducted by previous LPAs.  On 1/30/24, in association with a complaint (#27-AS-20231226132803) reported on 12/26/23. LPA Michael Bilger stated that, "R3 was observed to be urinating on the carpet and spitting up."  At the time, R3 was located in the hallway leading to the dining room. 

This LPA interviewed S1 and S6. Both stated that R3 had a medical condition that caused R3 to spit.  S1 stated that most of the time, S1 can anticipate when it will happen and can supply a barrier (i.e. a cup,) to catch the spit and will then dispose of it. S1 admitted that sometimes R3 spat on the floor and S1 had two different cleansers S1 used to clean and disinfect the area. S1 stated that they liked R3 and had a good rapport with them.  "R3 can't help it and I don't mind cleaning up after R3."  S2 and S3 informed this LPA that S1 was not always on duty and other staff were not as responsive, particularly at night when there weren't any housekeeping staff on duty. 

R3 had a change of condition which prompted R3 to be moved so that R3 could receive the appropriate care required. This LPA was told by the Executive Director that the "Policy and Procedure: Companion Rooms for Assisted Living and Memory Care," will be utilized to find a new roommate for R1.

The standard for the preponderance of evidence has been met and the allegation, "Staff do not ensure resident(s) are provided a healthy and safe environment," has been substantiated.  According to the California Code of Regulations, Title 22, this deficiency has been cited on the LIC 9099D page. 

A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Ashley Sylve.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240509155142
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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87307(d)(2)
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Pers. Accommo.& Services 87307(d)(2)
(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement was not met as evidenced by:

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Administrator stated that evening housekeeping staff has been added as well as a NOC shift housekeeper/laundry attendant to prevent future issues. The Administrator will submit the new schedule to CCL at kimberly.viarella@dss.ca.gov by the close of business 9/27/24.
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Based a review of records the housekeeping schedule was not adhered to in 9/10 weeks. This posed a potential risk to the health, safety and personal rights of residents in care.
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Type B
10/02/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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Administrator will conduct a training with housekeeping team on ALIS so they can document and communicate unusual occurrences, (feces on the wall, malodorous rooms) in order to improve and maintain a sanitary environment.
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This requirement was not met as evidenced by: Based on interviews, 3/3 staff stated R3 urinated and spit on the carpets and had thrown a feces filled diaper on the floor and at the walls. Based on a review of LPA records, an LPA had observed R3 urinating in a common area. This posed a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
05/09/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240509155142

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Sylve TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not provide reasonable accommodations for resident's roommate choice.
INVESTIGATION FINDINGS:
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On 09/25/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. The LPA identified herself upon arrival, stated the purpose of her visit and asked to speak with the Designated Facility Administrator / Executive Director (ED) Ashley Sylve. LPA met with the ED and a brief interview followed.

Regarding the allegation: "Staff do not provide reasonable accommodations for resident's roommate choice."

R1 told this LPA that they have moved 4 different times at Legacy Oaks. R1 left their accommodations in another room to move in with R3 as there was space available. The Administrator/Executive Director at that time did not utilize any tools to assess roommate compatibility. Since then the new Administrator instituted a process to assist with matching roommates based on compatibility. This policy titled "Policy and Procedure: Companion Rooms for Assisted Living and Memory Care" went into effect on 02/10/24. It is slightly
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240509155142
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: 09/25/2024
NARRATIVE
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over a page in length and includes an 8 step procedure. When R1 approached the Executive Director, Ashley Sylve, she said that she could initiate the process if R1 would like assistance in finding a new room and roommate. R1 refused stating that R1 did not want to move again. R3 was the original occupant of the room. R1 wanted a new roommate wanted the ED to remove R3. The Executive Director (ED) was willing to assist with finding R3 a new and more compatible roommate, but was not going to remove R3 from their room.

In the meantime, the ED worked on increasing the scheduled cleanings from once a week to twice a week. She also looked into some other strategies to eliminate the behaviors causing distress between the two roommates.

The standard for the preponderance of evidence was not met, the allegation, "Staff do not provide reasonable accommodations for resident's roommate choice." was UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during todays visit. A copy of this report along with APPEAL RIGHTS were provided and an exit interview was conducted with Ashley Sylve.




SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6