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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701122
Report Date: 01/03/2023
Date Signed: 01/03/2023 03:37:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221208154123
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:ORELLO, MELISSAFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 76DATE:
01/03/2023
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Alicia DuchineTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Facility staff did not ensure that resident's bathroom had toilet paper
-Facility does not have sufficient staff to meet the needs of the residents
-Facility staff does not ensure that hot food is served to the residents
INVESTIGATION FINDINGS:
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On 1/3/23 at 1:08 PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Assistant Administrator Alicia Duchine and explained the purpose of today's visit.

Regarding the allegation of Facility staff did not ensure that resident's bathroom had toilet paper, the Department found the following; based on interview, it was determined that residents are given 2-3 toilet paper rolls weekly. Resident 1 (R1) was using toilet paper and ran out while using the bathroom.

Regarding the allegation of Facility does not have sufficient staff to meet the needs of the residents, the Department found the following; based on interview and record review, it was determined that the facility has sufficient staffing and residents are getting their needs met.

Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
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 4
Control Number 27-AS-20221208154123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342701122
VISIT DATE: 01/03/2023
NARRATIVE
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Regarding the allegation of Facility staff does not ensure that hot food is served to the residents, the Department found the following; based on interview, it was determined that residents who get food delivered to their rooms, get their food delivered in trays that keep their food hot/ warm. R1 was known to wait to eat his/her food a little while after it was delivered. R1 also has a microwave to reheat food to their liking.

Based on interviews and record review, it is determined that the preponderance of evidence standard is not met, therefore these allegations are 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 occurred.

Exit interview conducted. A copy of this report was left upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/08/2022 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221208154123

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342701122
ADMINISTRATOR:ORELLO, MELISSAFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 76DATE:
01/03/2023
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Alicia DuchineTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Facility staff are not responsive to residents calls for assistance
-Facility staff did not ensure that resident received their medications as prescribed
INVESTIGATION FINDINGS:
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On 1/3/23 at 1:08 PM, Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Hopkins met with Assistant Administrator Alicia Duchine and explained the purpose of today's visit.

Regarding the allegation of Facility staff are not responsive to residents calls for assistance, the Department found the following; based on record review, it was determined that Resident 1 (R1) waited for assistance for over an hour.

Regarding the allegation of Facility staff did not ensure that resident received their medications as prescribed, the Department found the following; based on interview and record review, it was determined that staff was not sure if R1 received their medication due to the MAR not being signed for on multiple days. R1 stated that he/she did not receive their medication. Based on interview and record review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.
Exit interview held, Appeal Rights discussed and given, Copy of report given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221208154123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342701122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2023
Section Cited
CCR
87464(f)(4)
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 87464 Basic Services (f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This requirement was not as evidenced by:
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Administrator has agreed to conduct an in-service training with Med-Techs on ensuring residents get their medication and MAR's are filled out properly. POC due by 1/4/23 close of business.
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Based on interview and record review, the Licensee did not ensure R1 was given their medication and R1's MAR was properly filled out. This poses an immediate health and safety risk to residents in care.
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Type B
01/10/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2 To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not as evidenced by:
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Administrator has agreed to conduct an in-service training for caregivers giving assistance to residents. POC due by 1/10/23.
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Based on record review, the Licensee did not ensure that R1 was given assistance in a timely manner. This poses a potential health and safety risk to 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4