342701122-7-5-2024-27-AS-SRIN-D7GP26-20240724105525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 07/05/2024
Date Signed: 07/05/2024 01:27:39 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
12/20/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20231220111006

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: 102	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff are not ensuring resident receives proper care.

INVESTIGATION FINDINGS:

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On 07/05/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed. The DFA provided updates regarding the 4th of July event that occurred the previous day for residents and their guests.

During the walkthrough of the facility today, this LPA observed 3 residents and 1 caregiver playing cards. in the front activity lounge. LPA observed 1 resident in the adjacent lounge working on their laptop. LPA observed 1 housekeeper vacuuming the halls in Assisted Living and 1 Med Tech delivering medications room to room. LPA also observed 2 caregivers walking though the hallways. In Memory Care, LPA observed 3 residents in the sitting area being offered snacks and approximately12 residents in the dining / activities room watching TV and finishing up breakfast or having a snack. LPA was informed 2 staff were assisting a resident with a shower and LPA observed 2 others in the dining area along with a visiting RN.

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: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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 5

Control Number 27-AS-20231220111006

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: 07/05/2024

NARRATIVE

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The allegations: "Staff did not meet resident's toileting needs," and "Staff did not ensure that resident was adequately fed," were substantiated and deficiencies were cited by LPA Michael Bilger in COMPLAINT CONTROL NUMBER: 27-AS-20231226132803. As these two allegations refer to a lack of care, the preponderance of evidence gathered to substantiate these allegations also may be used to substantiate the allegation: “Facility staff are not ensuring resident receives proper care.” The complaint LPA Bilger investigated was reported on 12/26/23 and opened on 12/27/23. The following is an excerpt from that report by LPA Michael Bilger.

“On 2-16-24 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. During this investigation, LPA conducted facility observation on 1-30-24. Additional observations were conducted by LPA Viarella on 12-27-23 and 1-5-24. LPA also reviewed facility menus and conducted an interview with 5 staff members and 3 residents in care.

Allegation: Staff did not meet residents’ toileting needs. LPA conducted interviews and observations as noted above. Based on observations and interviews, it was determined that residen t1 (R1) required assistance with feeding and was brought to a designated area for such service on 1-30-24. R1 then exhibited an incontinent episode as R1 was waiting approximately 30 minutes for food to arrive. Additionally, based on observations conducted on 12-27-23, it was determined that a malodorous environment existed within the memory care unit including the smell of urine. LPA’s observation also revealed a dirty adult diaper in room #33 not properly disposed of. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff did not ensure that resident was adequately fed. LPA conducted interviews and observation as noted above. Based on observation and interviews, it was determined that resident 1 (R1) required assistance with feeding and brought to a designated area for such service on 1-30-24. During this observation, it was revealed that R1 was at the designated location for approximately 30 minutes without food or eating assistance and exhibited spitting up as well as an incontinent episode during this wait time. Interviews conducted revealed there was no set time for when R1 would receive his food service. As a result, there is a preponderance of evidence to conclude R1 was not fed adequately. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. The licensee was previously cited for

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20231220111006

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: 07/05/2024

NARRATIVE

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Section 87464(f)(4) on 2-16-24 and within the same investigation period for complaint # 27-AS-20231226091718.

As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights provided.”

As these similar allegations regarding care were investigated, cited, and plans of corrections were put in place, the findings for this investigation were also SUBSTANTIATED. No additional citations were delivered.

No other deficiencies were observed or cited during today's visit. A copy of this report along with APPEAL RIGHTS were provided.

Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
12/20/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20231220111006

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: 102	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ashley Sylve		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility administrator is not providing adequate attention to the management and administration of the facility and care.

INVESTIGATION FINDINGS:

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On 07/05/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator (DFA). LPA met with Ashley Sylve and a brief interview followed. The DFA provided updates regarding the 4th of July event that occurred the previous day for residents and their guests.

During the walkthrough of the facility today, this LPA observed 3 residents and 1 caregiver playing cards. in the front activity lounge. LPA observed 1 resident in the adjacent lounge working on their laptop. LPA observed 1 housekeeper vacuuming the halls in Assisted Living and 1 Med Tech delivery medications room to room. LPA also observed 2 caregivers walking thought the hallways. In Memory Care, LPA observed 3 residents in the sitting being offered snacks and approximately 12 residents in the dining /activities room watching TV and finishing up breakfast or having a snack. LPA was informed 2 staff were assisting a resident with a shower and LPA observed 2 others in the dining area along with a visiting RN.

Unsubstantiated

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: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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 5

Control Number 27-AS-20231220111006

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: 07/05/2024

NARRATIVE

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Regarding the allegation: Facility administrator is not providing adequate attention to the management and administration of the facility and care.

This LPA was at the facility on the following days opening and / or investigating complaints: 11/08/23, 11/21/23,12/05/23, and 12/06/23. This LPA also participated in a meeting on 11/09/23 where Community Care Licensing learned that the management company, Ally Senior Living, was being brought in to assist in bringing Legacy Oaks into compliance.

The current Designated Facility Administrator, Ashley Sylve began her employment at Legacy Oaks on 12/12/23. This LPA was also present at the facility on 12/12/23, 12/20/23, 12/27/23, and 1/05/24. During the month of December members of Ally Senior Living were frequently on site to assist with on boarding their new Executive Director (ED), Ashley Sylve. Along with reviewing, correcting and updating the facilities current policies and procedures, the ED was tasked with implementing the many plans of correction for the outstanding deficiencies that were cited or occurred prior to her arrival. Much of this work required research and communication with various departments, individual staff, as well as with the licensees. Through personal observation, interviews, and a review of records, the new ED along with assistance from vice presidents from Ally, hired new staff, retrained existing staff, and administered medications from the med cart when necessary.

Through interviews, this LPA learned that if a resident wanted to speak with the ED, they could either walk into her office if her door was open, or let the Concierge know at the front desk, and they would communicate the request to the ED. The ED would usually seek them out within 24 hours. This LPA has seen residents the ED's office, waiting outside of the office for a meeting, and speaking with the Concierge to relay a message that they would like to meet with the ED.

The standard for the preponderance of evidence could not be found and the department found the above allegation: "Facility administrator is not providing adequate attention to the management and administration of the facility and care," to be UNSUBSTANTIATED. An unsubstantiated finding means 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.

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

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