347003732-9-21-2023-27-AS-JFAN-CVVR2T-20230921123852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003732
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:40:00 PM

Document Has Been Signed on 09/21/2023 12:40 PM - 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 FACILITY		FACILITY NUMBER:	347003732
ADMINISTRATOR:	LEGGS, BRADFORD		FACILITY TYPE:	735
ADDRESS:	751 MOOSE CREEK WAY		TELEPHONE:	(209) 745-3980
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY: 6		CENSUS: 6	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kiesha Leggs		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/21/23 at approximately 8:45am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the Kiesha Leggs and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 3 bedrooms and 2 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 ambulatory residents. Residents were away at day program during visit. During this inspection 3 of 6 resident files and 2 of 6 staffing files were reviewed for regulatory compliance. Staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances.Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Water temperature in common bathroom reads 120F* which is within the regulated temperature range of 105F to 120. Temperature on the heating and air unit read 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 9/29/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 09/21/2023 12:40 PM - It Cannot Be Edited

Created By: Jennifer Fain On 09/21/2023 at 11:46 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: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)(1)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as 1 window screen was missing and 2 screens were torn out of 11 windows, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee states damaged and missing screens will be replaced or mended. Licensee will send proof of correction to LPA at jennifer.fain@dss.ca.gov by POC date.

Type B

Section Cited

CCR

80088(f)(1)

Fixtures, Furniture, Equipment, and Supplies

(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathrooms the trash cans had no lids, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Licensee states trashcans will be replaced. Licensee will send proof of correction to LPA at jennifer.fain@dss.ca.gov by POC date.

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:

Liza King

LICENSING EVALUATOR NAME:

Jennifer Fain

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FACILITY	FACILITY NUMBER: 347003732
	VISIT DATE: 09/21/2023

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First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. Facility conducts monthly fire drills.

LPA requested an updated copy of LIC500, LIC308, LIC 309, LIC402, LIC610E to be emailed to Jennifer.Fain@dss.ca.gov

The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Kiesha Leggs and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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