Legacy Oaks of Sacramento

Dispose of unused medications with required witness

Maintain comfortable room temperature at all times

Report suspected non-serious physical abuse within 24 hours

87211(c) Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Record review where 1 of 19 significant Incident reports selected randomily from the period of june 2025 to July 2025 described an incident where one resident physically assaulted another resident 6/27/25, ccl informed and recived report 7/20/25. Interview with a previous administrator who described a period of june 2025-July 2025 where the cacility was not staffed adequately to communicate with cclNot following this requirement poses a immediate risk to the health, safety, and personal rights clients in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident 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. When changes such as ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: record review where 5 of 19 Significant Incident Reports selected randomly from the period of June 2025 to July 2025 where the facilities observed chanage in condition did not also document a notification of the residents responsible person. Interview with a previous administrator who described a period in June 2025-July 2025 where the facility was not staffed adequately to communicate with representatives.Not following this requirement poses an immediate risk to the health, safety, and personal rights clients in care.

Report suspected non-serious physical abuse within 24 hours

Reporting Requirements 87211(c) Any suspected physical abuse...an elder or dependent adult shall be reported...within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1). The Licensee did not meet this requirement as evidenced by: Based on document review, the facility sent an SOC 341 on 1/13/26 for an incident that occurred on 1/5/26. The facility did not meet the 24 hour reporting requirement. This posed a potential threat to the health, safety, and/or personal rights of residents in care.

Personnel Records 87412(c) Licensees shall maintain... verification of required staff training and orientation. (1) The following staff training (B) For staff who provide direct care to residents with dementia...dementia special care, programming ... The Licensee did not meet this requirement as evidenced by: Based on a review of S1's file, they did not have the required dementia care training pre regulations. This posed a potential threat to the health, safety, and/or personal rights of residents in care.

Maintain facility in clean, safe, sanitary condition

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This is not met as evidenced by: Based on observationa and interview, the licensee did not ensure that the facility has been maintained overtime. During the course of the LPAs visits, several floors and tiles were observed to be lifting off the ground. This poses a potential, health,safety, and personal rights risks to persons in care.

Store centrally held medications in locked secure place

87465 "Incidental Medical and Dental (h) The following requirements shall apply...(2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...The Licensee did not meet the above requirement when: This LPA observed the door to the Medication Room in Assisted Living was open and the keys to the medication cart were in its lock.This posed an immediate risk to the health safety and personal rights of residents in care.

15699(a) states, "(a) When approved by the person responsible...special egress-control devices of the time-delay type, ...The devices shall conform to all of the following requirements:…"The Licensee did not meet the above requirement when: When this LPA toured the facility and tested the rear delay egress door in the Memory Care Community, the door opened without delay and the alarm did not sound.This posed an immediate risk to the health safety and personal rights of residents in care.

Ensure hazardous items are locked and not unattended

"Storage Space and Access (a) Except as specified in subsection (b)...cleaning solutions, poisonous substances...danger to residents are in locked storage and are not left unattended if outside the locked storage."The Licensee did not meet the above requirement when: LPA observed an unlocked laundry room with toxic chemicals accessible to residents in care. LPA also observed Clorox bathroom cleaner and Crest mouth wash under the sink in the bathroom of the behavioral intervention room (#37). This posed an immediate risk to the health safety and personal rights of residents in care.

Right to confidential records and approved disclosure

Additional Personal Rights of Residents in Privately Operated Facilities CCR 87468.2 "(a) In addition... Residents in All Facilities...rights: (2) To have their records and personal information remain confidential... The Licensee did not meet the above regulation when: LPA observed that both the entrance door to the Business Office, and its interior door to the smaller office inside, were open and a file drawer was left open leaving residents confidential financial information available.This posed a potential threat to the health, safety and personal rights of residents in care.

Maintenance and operation requirements for facilities

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation was not met as evidenced by based on observation and interviews that took place on 7/29/25 and 8/21/25, which corroborate the conditioning system was not fully functioning and maintained in good repair especially on dates of exreme heat. Additionally, one hallway area was recorded to be over 85 degrees on these dates. This poses an potential health and safety risk to residents in care, especially those with medical conditions impacted by heat.

Regular observation and documentation of resident changes

"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: 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.

Facility personnel sufficiency and competence

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The Licensee did not meet the above requirement when: Based on a review of records, in 11 out of 66 occurrences, staff did not respond to a resident's call light in a timely manner with 4 of those response times being in excess of 1 hour. That posed/es a potential risk to the health, safety, and personal rights of residents in care.

" (B) Hand hygiene shall be conducted as follows: ...5. Immediately before putting gloves on and immediately after removing gloves." This requirement was not met as evidenced by: Based on interviews, caregivers do not consistently wash their hands after removing their gloves, which poses a potential health, safety, and/or personal rights risk.

Maintain facility in clean, safe, sanitary condition

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: 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.