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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:30:48 PM

Unsubstantiated


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
12/11/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231211205849
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: 102DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Sylve TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not protect resident from humiliation or abuse.
Facility did not ensure the privacy of residents in care when staff brought another resident into a resident's room without permission.
Facility did not protect the dignity of residents in care.
INVESTIGATION FINDINGS:
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On 07/03/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. The 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.

The DFA described a new snack / coffee bar area that was to be added to the large Activities Lounge at the front of the building. The DFA stated that it would provide more autonomy and be more convenient for the residents. She went on to add that she was continuing her interviews for a new Activities Director and was going to add a second Activities Assistant in order to provide more outings and specialized activities for smaller groups. At the moment they were offering activities led by their current Activities Assistant, but the goal was to offer a more robust and inclusive program.

The LPA and the DFA conducted a walkthrough of the facility. LPA observed water stations and standing
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: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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 6
Control Number 27-AS-20231211205849
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: 07/03/2024
NARRATIVE
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fans throughout the facility to assist with keeping the residents hydrated and cool.
LPA observed Housekeepers in both Assisted Living and Memory Care.  Med Techs were stationed outside of the two respective dining rooms. LPA observed approximately 30 residents being served lunch in the Assisted Living dining room and 12 in the Memory Care dining room.  Additional residents were still arriving for lunch. LPA observed 3 Carestaff assisting residents in Memory Care and 3 in Assisted Living. 

Regarding the allegation: Facility did not protect resident from humiliation or abuse. 
In early June of 2022, it was alleged that a MedTech working in Memory Care brought a male resident into a partially dressed female resident's room as a way to get the male resident to take his medication.  This LPA interviewed 8 staff (current and former) as well as a member of another reporting agency.  None of the staff interviewed could corroborate that the above incident happened.  This LPA conducted a search of the electronic files for the summer of 2022 and could not find any LIC 624 or SOC 341 reports that matched this allegation.  All Carestaff and MedTechs were mandated reporters by law and were required to report incidents of abuse.  As this was said to have occurred over 2 years ago, many of the staff that had worked in memory care in 2022 were no longer at Legacy Oaks and difficult to reach.  The standard for the preponderance of evidence was not met and the department found this 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 the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: Facility did not ensure the privacy of residents in care when staff brought another resident into a resident's room without permission.
As this allegation was related to the prior one, the department found it too, to be UNSUBSTANTIATED. A finding of 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.

Regarding the allegation: Facility did not protect the dignity of residents in care.
As this allegation was related to the first one, the department found it too, to be UNSUBSTANTIATED. A finding of 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20231211205849
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: 07/03/2024
NARRATIVE
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According to the California Code of Regulations, Title 22, no 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: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
12/11/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20231211205849

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: DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Sylve TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not report an incident to CCL as required for mandated reporters.
INVESTIGATION FINDINGS:
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On 07/03/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. The 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 did not report an incident to CCL as required for mandated reporters.
During the course of this investigation, this LPA learned that none of the staff interviewed stated that they remembered any incident like the one mentioned in the complaint happening when they were working in 2022. When this LPA interviewed S7, S7 stated that sometime in 2023, a staff member brought a social media post to S7's attention that described the incident. S7 stated that a year had gone by before they became aware of the allegation and felt that it was untrue. "If it was true and you cared about the residents, why wouldn’t you say something to someone?" S6 and S2 also stated that someone told them
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: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20231211205849
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: 07/03/2024
NARRATIVE
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about the social media post and that was how they first heard about the incident described in the allegation. S6 stated that they shared the information with the Executive Director at the time, S5 and thought S5 would handle the situation. S5 was no longer employed at Legacy Oaks and was replaced by the current Designated Administrator, Ashley Sylve.

After reviewing the electronic files for the summer of 2022, this LPA found that Community Care Licensing had no record of a complaint being reported. LPA contacted the Ombudsman.  The Ombudsman confirmed that he had received an SOC341 and had conducted interviews as part of his investigation into the incident.  He too could not find a preponderance of evidence to substantiate the allegations in the complaint. 

Staff at Legacy Oaks were aware of the allegations from two sources: it was brought to their attention through the social media post and it was brought to their attention by the Ombudsman's investigation.  On 12/12/23, this LPA and the Vice President of Health and Wellness (S8) searched through a binders of facility incident reports for 2022 and could not locate a report for this complaint.  As it was not reported in 2022, when the post was brought to management's attention in 2023, it should have reported to CCL immediately, per reporting requirement regulations for mandated reporters.   The preponderance for the standard of evidence has been met and the allegation, "Facility did not report an incident to CCL as required for mandated reporters," has been SUBSTANTIATED.  This deficiency was cited on the LIC 9099 D page and because it was a repeat violation Civil Penalties were incurred.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20231211205849
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: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements 87211(a)(1)
(a) Each licensee shall furnish...reports...
(1) A written report shall be submitted specified in (A) through (D) below. The facility was not in compliance with the above regulation as evidenced by:
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Based on interviews and a records review, 4 staff stated they learned of the social media post describing an incident but none re-ported it to CCL required. The facility could provide proof an LIC 624 or an SOC 341 had been sent. This posed/poses a potential threat to the health,safety, and personal rights of the 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6