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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342702896
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:36:52 PM

Document Has Been Signed on 12/11/2024 01:36 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:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR/
DIRECTOR:		SYLVE, ASHLEYFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY: 160CENSUS: DATE:
12/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Ashley Sylve TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/11/24, an unannounced prelicensing inspection was conducted by Licensing Program Analyst (LPA) Kimberly Viarella at this facility. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator / Executive Director (ED) Ashley Sylve. The two met and a brief interview followed.

LPA began the visit by comparing the LIC 500 (the staff roster) with the Guardian roster to ensure that all staff had the proper background clearances to be working in this facility. All were in compliance at the time of this inspection.

The LPA and the (ED) then toured the facility. LPA inspected kitchen and found that it had enough non-perishable food items for 7 days and perishable items for 2 days. All were packaged and dated appropriately. LPA observed an increase in the amount and variety of fresh fruits and vegetables since the last visit to this facility and the kitchen manager had purchased more low salt/no salt items.

LPA observed that fire extinguishers throughout the facility were last inspected on 03/05/24 and were in compliance at the time of this inspection.

During the walkthrough LPA observed 2 housekeeping carts in the hallway with the cleaning supplies locked and inaccessible to residents in care. LPA observed 7 residents in assisted living playing Pokeno being led by a staff member. LPA observed 15 residents in memory care in the dining/activity room watching a holiday movie and being supervised by 2 care staff. The memory care director was also available and a third staff member was on break at the time of this walkthrough. All communal areas were decorated for the winter holidays by staff and residents. LPA visited rooms 34 and 35 and found them to contain all of the required furniture, furnishings and lighting to be in compliance at the time of this inspection.

LPA visited the Medication Room and inspected the medication cart. LPA pulled a random sample of 12
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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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: LEGACY OAKS OF SACRAMENTO
FACILITY NUMBER: 342702896
VISIT DATE: 12/11/2024
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prescription medications and verified that none had expired and that pill packs observed were up to date with the medications administered. LPA also reviewed administration and destruction procedures with the ED, along with the procedures for administering PRN medications.

LPA also observed a gingerbread decorating/eating activity in the front activity room that included residents from both assisted living and memory care. There were over 20 residents present and 8 staff assisting.

LPA toured 2 rooms in assisted living and found them to have the required furniture, furnishings, and lighting to be in compliance at the time of this inspection. Bathrooms contained the required grab bars, toilet paper, bath mats and trash cans. LPA measured the hot water temperature and found it to be 105.1 degrees Fahrenheit and in compliance.

LPA conducted an inspection of the exterior of the building. There were two sheds. LPA requested that they be unlocked and LPA observed supplies for the Activities Department in one shed. The second shed contained mini refrigerators, fans, and tables as well as other maintenance supplies.

All screens and gutters were in good repair an there was no debris on the grounds surrounding the facility at the time of this inspection. There was a covered structure designated as a smoking area and a second structure which needed a new covering that would provide shade for non-smokers. The ED stated that they were collecting bids for the repair of the second structure. At the present time the structure is without a covering but it did not present a safety hazard to residents in care.

LPA then conducted a file review for 3 residents (R1, R2, and R3) as well as 3 staff (S1, S2, and S3). All files were in compliance at the time of this inspection.

According to the California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's visit. The facility passed its inspection and completed Comp III. LPA to notify the Centralized Applications Bureau (CAB) by the close of business today.

A copy of this report was provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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