342702896-9-25-2025-27-AS-SRIN-DPV2UP-20251230164240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 09/25/2025
Date Signed: 09/25/2025 04:01:55 PM

Unsubstantiated

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
04/24/2025 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20250424084313

FACILITY NAME:	LEGACY OAKS OF SACRAMENTO		FACILITY NUMBER:	342702896
ADMINISTRATOR:	JONATHAN AGUILAR		FACILITY TYPE:	740
ADDRESS:	1922 MORSE AVENUE		TELEPHONE:	(559) 313-8062
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	160	CENSUS: 83	DATE:	09/25/2025
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Ashley Sylve, Quality Assurance/Performance Improvement Director (RQAPID)/Designee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff keep taking residents pendent away.

INVESTIGATION FINDINGS:

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On 09/25/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to deliver the findings of this investigation into the above complaint. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee. LPA met with Sylve and a brief meeting followed.

LPA conducted interviews and a review of records during the course of this investigation. This LPA interviewed staff S1-S4. This LPA learned from S2, S3, and S4, that when staff would assist the resident (R1) with meals, changing, or showers, they would remove the pendent and put it on the small table in R1's room, which was out of R1's reach. They would then return the pendant to R1's neck following the activity. S2, S3, and S4 all mentioned the possibility that staff sometimes forgot to put the pendant back on R1 after they provided assistance with activities of daily living. That being said, 3 out of the 4 staff interviewed stated they had personally seen the pendent on the table out of R1's reach and each

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250424084313

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: 342702896
	VISIT DATE: 09/25/2025

NARRATIVE

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stated that when they did, they put it back around R1's neck.

Based on a review of the pendant call alert, there were days when either R1 did not have a pendant (both the family and facility staff commented that it had been lost and replaced) or it was not activated. This LPA learned the following from a review of the call logs. From 05/01/25 though 05/14/25, R1 activated their pendant 66 times, out of that number, 11 of these calls for assistance took longer than 15 minutes to respond to. On 05/01/25, It took staff 2 hours and 26 minutes to address R1's call. On 05/02/25, it took 1 hour and 2 minutes. On 05/06/25, it took another 1 hour and 2 minutes. On 05/08/25, it took 31 minutes, and on 05/09/25, it took 1 hour and 20 minutes.

The Department found the allegation "Staff keep taking residents pendent away," 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.

However, during this investigation the Department also learned that staff were not responding to the resident's call alert in a timely manner and that deficiency will be addressed during a future case management visit.

According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit and a copy of this report was provided along with APPEAL Rights and an exit interview was conducted with Sylve.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

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