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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701122
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:37:08 PM


Document Has Been Signed on 07/25/2024 04:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 104DATE:
07/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Ashley SylveTIME COMPLETED:
05:15 PM
NARRATIVE
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On 7-25-24 at 3:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding staffing levels and fall precautions. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. LPA reviewed investigative information from complaint #27-AS-20240424094125 including but not limited to: Staff interviews, previous incident reports, care plans and assessments pertaining to resident1 (R1). Based on the above information, it was determined that R1 required total assistance in multiple activity of daily living (ADL) categories including 2-person transfer assistance. Record reviews revealed that R1 sustained a total of 23 unwitnessed falls between 3/11/2023 and 4/14/2024. Interviews also revealed that facility’s fall prevention protocols include utilizing mats on the floor and a one-to-one sitter as necessary, however, evidence did not exist to conclude these interventions were put in place as part of R1’s fall prevention plan. Additionally, it was determined that facility used an outside paramedic service to assist lift assistance for R1 multiple times throughout R1’s residency. Interviews further revealed that R1 required one to one care assistance to aid in fall prevention.

As a result of today’s case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights provided. LIC 811 provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/25/2024 04:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87411(a)

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Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidenced by:
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Licensee to submit an updated plan outlining how facility will provide adequate staffing needs for residents identified as fall risks as well as other special needs. Plan to be submitted to LPA by POC due date.
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Based on interviews and record reviews, it was determined that R1 required one to one care assistance which was not provided by Licensee. This posed an immediate health and safety risk to resident in care.
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Type A
07/26/2024
Section Cited
CCR87405(h)(5)

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Administrator Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs..This requirement was not met as evidenced by:
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Licensee to read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record reviews, Administrator did not ensure the necessary fall prevention protocol necessary for R1’s fall prevention needs. This posed an immediate health and safety risk to resident 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2