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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:31:21 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
04/24/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240424094125
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
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Ashley SylveTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident sustained multiple falls due to lack of supervision
INVESTIGATION FINDINGS:
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On 7-25-24 at 2:36pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. During this investigation, the Department conducted interviews with five staff members, three residents and additional witness. The Department also reviewed file documentation including physician’s report, appraisal forms, care plans, incident reports, hospital medical records and paramedics reports all pertaining to resident1 (R1).

Allegation: Resident sustained multiple falls due to lack of supervision. The Department conducted interviews and record reviews as stated above. Based on interviews and record reviews it was determined that R1 was sent to the hospital a total of 12 times from 3/1/2023 to 5/12/2024; eight of the visits to the hospital were due to falls.
{Cont on 9099C}
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20240424094125
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: 07/25/2024
NARRATIVE
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A record review of incident reports revealed R1 sustained falls between 1/11/2024 to 3/26/2024. An additional review of facility’s online system revealed R1 sustained a total of 23 unwitnessed falls between 3/10/2023 and 4/14/2024. Interviews conducted further revealed R1 was a fall risk and had sustained multiple falls at the facility. Although interviews revealed an increase in checks for R1, there was no additional evidence provided through interviews or record reviews that additional fall preventions were in place including safety mats on the floor and increased staff supervision as set forth in facility’s established fall prevention measures. The facility fall prevention measures were revealed through interviews. On 3-26-24, R1 was sent to hospital and received a resulting diagnosis of a ruptured spleen.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. A civil penalty in the amount of $500 is issued in addition to a citation due to resident sustaining a “splenic laceration with a large subcapsular splenic hematoma” obtained in conjunction with R1’s history of falls. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240424094125
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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
HSC
1569.312(e)
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Basic Service Requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by:
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Licensee to submit a plan ensuring the initiation of fall prevention measures for residents identified as fall risks. Plan to be submitted to LPA by POC due date.
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Based on interviews and record reviews, facility did not initiate their established fall prevention measures after learning of R1’s multiple falls leading to an injury of R1. This posed an immediate health and safety risk to residents in care.
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Licensee to ensure completed staff training on fall prevention. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 8-8-24.
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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
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
04/24/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240424094125

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:
07/25/2024
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Ashley SylveTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident resulting in hospitalization
Facility staff did not meet resident's need for hydration
INVESTIGATION FINDINGS:
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On 7-25-24 at 2:36pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Ashley Sylve and explained the purpose of the visit. During this investigation, the Department conducted interviews with five staff members, three residents and two additional witnesses. The Department also reviewed file documentation including physician’s report, appraisal forms, care plans, incident reports, hospital medical records and paramedics reports all pertaining to resident1 (R1).

Allegation: Facility staff did not seek timely medical attention for resident resulting in hospitalization. The Department conducted interviews and record reviews as stated above. Based on interview, it was alleged that R1’s responsible person called 911 after R1 fell on approximately 3/21/2024 or 3/22/2024.

{Cont on 9099C}
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240424094125
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: 07/25/2024
NARRATIVE
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Additional interviews and record reviews indicated R1’s last fall at facility was on 3/11/2024 but did not go to the hospital as no injuries were observed. Additional record reviews and interviews further indicated R1 did not sustain a fall on either 3/21/2024 or 3/22/2024, and R1 did not show any signs of pain or being injured until 3/26/2024 when R1 was transported to the hospital.
As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff did not meet resident’s need for hydration. The Department conducted interviews and record reviews as stated above. Based on these interviews and record reviews, it was revealed that R1 sustained multiple falls and was sent to the hospital multiple times during her residency at the facility, however, the evidence reviewed did not indicate R1 as being dehydrated or not receiving adequate amount of hydration. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Ashley Sylve and a copy of this report was provided to Ashley. Appeal rights 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5