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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 08/15/2024
Date Signed: 08/27/2024 01:57:18 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
04/29/2024 and conducted by Evaluator Charlie Yang
COMPLAINT CONTROL NUMBER: 27-AS-20240429181015
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: 101DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley SylveTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 08/15/2024 by this Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Ashley Sylve, and a brief interview was conducted with her at this time.
Current census was 101 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and its designated representative, Ashley Sylve, at this time.
Based on interviews and a review of the forms and documents conducted during the course of this investigation, it was learned that this facility served an eviction letter to R1, and R1's responsible party, on the date of 03/15/2024. It was learned that this eviction letter was created and dated on 03/15/2024 but was not actually mailed out until the date of 03/20/2024 to R1 and R1's responsible party. This did not meet the requirements of giving the resident and their responsible party the required 30 days prior to the eviction date.
In addition, it was learned that the eviction letter that was sent to R1, and R1's responsible party, was
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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-20240429181015
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: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
87224
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Eviction Procedures
The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a
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This facility was investigated and cited for this same allegation from a prior complaint investigation, and follow up case management visit, as well.
The investigation will defer to this prior complaint investigation and associated deficiency, with plan of correction, that was
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need not previously identified, and/or a change of use of the facility.
This facility was found to be deficient as evidenced by not giving the resident and their responsible party the required 30 days notice prior to the eviction date.
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conducted and cited on 04/23/2024.
No further plan of correction was requested at the time of this complaint investigation.
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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: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240429181015
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: 08/15/2024
NARRATIVE
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incomplete and did not contain all of the references and information contained on the facility's version.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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
04/29/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240429181015

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: 101DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley SylveTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff does not ensure resident's medication is being administered as prescribed.

Staff does not communicate with resident's responsible party regarding change of resident's care plan.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 08/15/2024 by this Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Ashley Sylve, and a brief interview was conducted with her at this time.
Current census was 101 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and its designated representative, Ashley Sylve, at this time.
Based on interviews and a review of the forms and documents conducted during the course of this investigation, it was learned that R1 was often times not compliant with taking R1's medications throughout the day as prescribed by the licensed medical professional. It was learned that this facility, and its personnel, always attempted to re-direct R1 when this occurred but were successful at times but also unsuccessful at times as well.
It was learned that the facility personnel did follow facility protocol and properly notified the responsible licensed medical professional often times via fax detailing the medications that were refused or missed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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-20240429181015
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: 08/15/2024
NARRATIVE
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It was learned that any changes to the care plan or levels of care to the resident by R1's responsible licensed medical professional were entered and shared with all care staff. These notes were updated and then relayed to the responsible party for R1.
Based on a review of the facility care notes for the period of 12/11/2022 through 05/01/2024, it was learned that R1 had a total of 34 incidents which took place in over 34 locations throughout this facility. These incidents ranged from aggressive acts (4), behavioral issues (8), and medical emergencies (5).
The various locations that these incidents took place ranged from the facility hallways (15), resident's room (9), and dining area (5).
It was learned that the responsible party for R1 was properly notified when these incidents took place. It was learned that notifications were either performed by the care staff present on duty or by the facility designated Administrator as well.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5