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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 08/06/2025
Date Signed: 08/06/2025 03:51:14 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
08/04/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250804095207
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 87DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley Sylve, Quality Assurance/Performance Improvement Director (RQAPID)/Designee TIME COMPLETED:
09:44 AM
ALLEGATION(S):
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Room used for behavioral interventions is malodorous.
INVESTIGATION FINDINGS:
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On 08/06/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open an investigation into the above allegation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator/Executive Director (ED). The ED was out of the building and there was not a Designee present so Ashley Sylve, the Quality Assurance/Performance Improvement Director (RQAPID)/Designee was called to come to the facility. Another staff member, S5, accompanied this LPA on a walkthrough of the facility while they waited for the Designee to arrive.

LPA observed the following during her walkthrough. In the common room of assisted living, 2 residents were seated in front of a snack cart waiting for Bingo that was scheduled later in the morning. LPA observed water stations set up throughout the facility with cups and pitchers of ice water. LPA observed 2 housekeeping carts and staff servicing resident rooms. LPA observed a medication pass being conducted at one resident's room. LPA observed the rear door to the facility leading to the building was propped
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
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-20250804095207
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: 08/06/2025
NARRATIVE
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open. LPA closed the door and provided technical assistance to staff regarding the need to keep doors
without screens closed to ensure the facility was kept free from insects and pests.

When this LPA entered the memory care community, she checked the rear exit and it was not alarmed and the door opened freely to the back parking lot. This deficiency will be cited during a follow-up case management visit.

LPA also observed residents' artwork (painted canvases) posted on the walls in the hallways of the community. There were 11 residents in the dining room enjoying a morning snack and 4 residents relaxing on furniture in the adjacent hallway supervised by staff.

Upon returning to the assisted living area of the community, LPA observed an unlocked laundry room with detergent present and accessible to residents in care. This deficiency will be cited during the future case management. LPA also observed 10 residents playing Bingo led by the activities assistant. 4 other residents were on an outing to botanical gardens supervised by 2 staff.

When LPA returned to the lobby area of the facility, LPA noted that the door to the Medication Room was open and that the keys were in the medication cart and the cart was unlocked. There were no medication technicians in the room at this time. LPA interviewed 3 staff members (S1, S2, and S3) who stated that they were instructed to leave the door open so that residents would be able to find them more readily when they were in the med room and not in the community. LPA reminded them that there was no one present in the room at the time the LPA walked in; the door should have been closed and locked so that all medications were inaccessible to residents in care. This deficiency will be cited in the follow-up case management visit.

Regarding the allegation: Room used for behavioral interventions is malodorous.

Legacy Oaks launched a program where they utilized staff trained on behavioral intervention techniques to assist and redirect residents having behavioral expressions. Residents from both the assisted living and the memory care communities were brought to room 37 where they could get away from triggers, play a game, watch a movie, and behaviors could be de-escalated. LPA visited room 37 which was designed to be a resident room, and observed the following:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250804095207
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: 08/06/2025
NARRATIVE
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The window was open and a fan was seated on the floor on one side of the room and blowing the decorations on the wall opposite. There was a diffuser on the counter. LPA observed shelves with games and activities along with a table in the center of the room surrounded by folding chairs. There was a sofa and other furnishings and decorations. LPA observed that the brown carpet was stained in several places, the largest being in front of the sofa area and another extending toward the kitchenette. LPA also observed that the baseboard molding adjacent to the carpet was warped and falling down in places. By the sink, it was completely detached and on the floor. LPA took pictures for documentation purposes.

LPA then observed a small bookcase slightly in front of the bathroom door. LPA and a staff person moved the bookcase and this LPA entered the bathroom. LPA observed a broken toilet. The tank had been removed and was in the bathtub. The toilet had dirty brown standing water and toilet paper in it. The vanity was missing the door to the cabinet under the sink and Clorox and other toxic cleaning supplies were observed underneath. The tub/shower unit also had a metal shelving unit in it along with 2 buckets. One of the buckets approximately (3-5 gallons) had standing water in it. LPA took pictures for documentation purposes. A staff member, S1 walked in while this LPA was recording observations. LPA interviewed S1 and asked about the condition of the room. S1 stated they were told the room smelled badly because of the carpet and that was why they were constantly cleaning and brought in the air diffuser.

LPA observed that her own eyes were irritated upon entering the room. When Designee Ashley Sylve arrived, LPA requested that the diffuser and fan be shut off and the window closed to see if she could assess what the room smelled like without them. LPA returned later with Sylve and found the room to be malodorous. LPA also observed that maintenance had begun removing all the furniture. Sylve stated that the room was being emptied out in preparation for maintenance to conduct all necessary repairs. While the room was used for behavioral interventions, it was not being used for the purpose that was stated in the facility's plan of operation and facility sketch. This violation will be cited in the follow-up case management visit along with the others motioned previously. Sylve stated they would conduct their Residential Habitation (RH) program in the activities rooms going forward. Room 37 room would be prepared for resident occupancy in order to return to compliance.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250804095207
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement was not met as evidenced by:
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The Designee stated that the room will emptied by the close of business today 08/06/25 and residents will not have access to it until all repairs have been completed and the room is compliant and ready for resident occupancy.
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Based on observation and interviews with S1 S2 and S3, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair and the dirty standing water in the broken toilet. This posed/poses an immediate risk to the health, safety, and personal rights 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250804095207
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: 08/06/2025
NARRATIVE
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The allegation: Room used for behavioral interventions is malodorous.

Based on observations and interviews with S2, S3, and S4, room 37 was found to be malodorous and unsanitary when this LPA observed the stained carpet, baseboard molding in disrepair, and the dirty brown standing water and toilet paper in the broken toilet in the bathroom.

Prior to closing this report, this LPA also observed that the Business Office door was open with no staff present, and resident files with confidential financial information were left accessible to anyone walking by. One of the filing cabinet drawers was left open and in plain site.

According to the California Code of Regulations, Title 22, due to time constraints, the other deficiencies
noted in this report will be cited in a follow-up case management visit. A copy of this report was provided along with APPEAL RIGHTS and and exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5