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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003732
Report Date: 12/05/2023
Date Signed: 12/05/2023 10:50:08 AM

Document Has Been Signed on 12/05/2023 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LEGGS ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
347003732
ADMINISTRATOR:LEGGS, BRADFORDFACILITY TYPE:
735
ADDRESS:751 MOOSE CREEK WAYTELEPHONE:
(209) 745-3980
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 6CENSUS: 3DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Phyllis LeggsTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. LPA was later met by Licensee Phyllis Leggs.

LPA Valerio received a Notice of Sanction Letter and a Facility Action Report from Alta California Regional Center (ACRC). On 11/08/23, ACRC conducted an announced visit and identified substantial inadequacies. The facility was cited for Title 17 56054(a)(4) and 56054(a)(7). Licensee/Administrator implemented a Corrective Action Plan (CAP) with ACRC. The facility has been placed on Sanctions with ACRC until the CAP is completed in full.

LPA Valerio and facility staff toured the physical plant to ensure compliance with Title 22 regulations. LPA observed common areas, garage, back yard, staff office, kitchen area, and main hallway. Common areas were fully furnished. The facility was observed to have an adequate food supply. The residents were observed in their rooms and did not attend day program for the day. The facility was practicing infection control protocols. No health or safety concerns observed.

LPA observed facility files. LPA observed Staff 1 (S1) training for January 2023 - December 2023. LPA observed 1 hour of in-service training for each month dating January to September 2023, 12 hours of staff training completed with JTLB Training, 5 hours of training with NetCE in March of 2023, and 10 hours of training with NetCE in January of 2023. Copies of documentation were obtained for future reference.

Per California Code of regulations (CCR) - Title 22 - deficiencies are being cited today on the attached LIC 809 - D page. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided at the time of the visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2023 10:50 AM - It Cannot Be Edited


Created By: Christina Valerio On 12/05/2023 at 09:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGGS ADULT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 347003732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
80070(a)

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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by:
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Licensee will send a copy of in-service training provided to staff related to completing client records by POC due date
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Based on records review, the licensee did not ensure the Medication Administrator Record for Resident 1 was signed off by staff, which poses a potential health, safety, or personal rights 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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


LIC809 (FAS) - (06/04)
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