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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 10/02/2025
Date Signed: 10/02/2025 12:20:58 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
01/31/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250131105732
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 80DATE:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to deliver findings on this complaint. LPA Moleski met with facility administrator Ashley Sylve and explained the purpose of the visit.

LPA Moleski reviewed a death report for (R1). R1 was found unresponsive on the morning on 1/29/25. First responders declared R1 dead as of 8:30 a.m. R1 was 90 years old, and had a primary diagnosis of atrial fibrillation, diabetes, Hodgkin lymphoma, and had a history of stroke, according to their resident file. R1 was not receiving hospice care. The Community Care Licensing Division (CCLD) reviewed a death certificate for R1. R1's immediate cause of death was identified as a heart attack, with leading causes of myocardial hypotension, myocardial infarction, and coronary artery disease.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
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
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
01/31/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250131105732

FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 80DATE:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ashley SylveTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Facility staff are not checking on residents during their shifts
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint. LPA Moleski met with facility administrator Ashley Sylve and explained the purpose of the visit.

LPA Moleski reviewed a death report for (R1). R1 was found unresponsive on the morning on 1/29/25. First responders declared R1 dead as of 8:30 a.m. R1 was 90 years old, and had a primary diagnosis of atrial fibrillation, diabetes, Hodgkin lymphoma, and had a history of stroke, according to their resident file. The Community Care Licensing Division (CCLD) reviewed a death certificate for R1. R1's immediate cause of death was identified as a heart attack, with leading causes of myocardial hypotension, myocardial infarction, and coronary artery disease. Although R1's death was reported to the local coroner's office, no autopsy or biopsy were performed, and the death certificate did not indicate the death was suspicious. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250131105732
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: 10/02/2025
NARRATIVE
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An incident report submitted to CCLD regarding the circumstances of R1's death indicated that first responders estimated R1's time of death as some time "earlier that morning" based on R1's body temperature and the rigor mortis present in R1's body.

LPA Moleski reviewed R1's care plan, dated 1/6/25. R1 was required to have checks every two hours, per the care plan. R1's appraisal, dated 1/6/25, indicated that R1 required special observation and/or night supervision. The appraisal was signed by Sylve on 1/6/25.

LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning. In a statement, one staff member who alerted first responders to R1's condition (S11) said EMTs estimated R1 had died "during the overnight hours based on [R1's] physical state."

LPA Moleski reviewed R1's call button responses and observed R1's last call for assistance was just before 11 p.m., presumably when S10 provided R1 with water. In an interview, Sylve said that, based on witness statements, the last time R1 was checked on was at 2 a.m.

The department has determined the following as it relates to the allegation that facility staff are not checking on residents during their shifts:

Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87466. An exit interview was held with Sylve. A copy of this report and appeal rights were left with Sylve.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250131105732
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: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2025
Section Cited
CCR
87466
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"The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs..." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski a written plan to address two hour checks by POC due date, with additional training to follow.
vincent.moleski@dss.ca.gov
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Based on record review and interviews, a resident required two hour checks per their care plan, but did not receive these checks on the night of their death, which poses an immediate health, safety, and/or personal rights risk.
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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: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250131105732
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: 10/02/2025
NARRATIVE
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 Although R1's death was reported to the local coroner's office, no autopsy or biopsy were performed, and R1's death certificate did not indicate the death was suspicious.

LPA Moleski reviewed witness statements taken by facility staff regarding R1's death. Staff members who observed R1 on the evening of 1/28/25 indicated that R1 appeared normal, and was observed sitting up. An overnight caregiver on duty assigned to R1's care (S10) said in a statement that they had given water to R1 around 11 p.m. on 1/28/29, and passed by R1's room again around 2 a.m. and saw R1 asleep. Witness statements do not indicate that any additional contact was made with R1 until R1 was found unresponsive by housekeeping staff in the morning.

The department has determined the following as it relates to the allegation of a questionable death:

Based on record review, the above allegation is UNSUBSTANTIATED, which 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.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Sylve.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5