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Inspection visit

Complaint

LEGACY OAKS OF SACRAMENTOLicense 342702896
Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

care notes dated 12/02/24, S1 wrote, "R1 stated they had a lighter missing, and I found several brand new lighters as well as old ones. R1 stated that money was missing, and I found multiple one-dollar bills, twenties, and 2 tens. I gave them to R1. R1 mentioned that a bag of change was missing, and I also found that. R1 has a lot of things… and R1 doesn't always know where they are, so I believe everything could have been misplaced." S1 also told this LPA that R1 also located their missing cologne. This LPA also learned during the course of this investigation, that R1 was independent and would utilize their mobility device to go out into the community. The device had pouches strapped to it on both sides to carry personal items. Based on interviews with S1, S5, and S7, combined with this LPA's personal observations on 01/02/25, and today, 06/04/25, R1 frequently left these side pouches opened. S1 suggested that when R1 took the bus to the mall or other places in the community, their wallet might have fallen out or someone might have taken it from the open side pouch. S1 said that on several occasions, they would remind R1 to zipper the pouches closed because S1 would notice that they were bunched up and items would be on the verge of falling out. This LPA also reviewed incident reports pertaining to R2 and there was no previous history of, or suspicion of, theft in their background. There were also no incident reports related to behaviors. This LPA interviewed R2 who stated that they would never take anyone else's property and that they were just glad they had moved into a different room. The Department finds the allegation, "Resident's wallet was stolen while in care," to be UNSUBSTANTIATED. A finding of unsubstantiated means although the allegation may have happened or is valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Regarding: "Resident was treated disrespectfully by medication technicians." R1 believed that R2 had stolen their personal belongings. When interviewed, R1 told this LPA that anyone who was friends with R2 was also a liar and a thief."  S1 stated that R1 felt that staff should be loyal to R1 and if R1 was mad at R2, then staff should also be mad at R2 and not interact with R2." When R1 saw medication technicians (medtechs) administering medications to R2, R1 stated that they became afraid if the medtechs were friends with R2 "they might poison R1." R1 refused to take their medications from certain medtechs. R1 refused a total of 24 doses of prescribed medications on 12/16/24 and 12/23/24. This LPA conducted a review of records for the 2 medtechs in question and there were no disciplinary actions, similar or related to, the above allegation in their personnel files. LPA was provided 3 incident reports for R1. On 12/09/24 "R1 was screaming at staff and residents in the dining room. R1 was upset about something to do with their roommate." The report went on to say that R1 persisted to yell and use foul language and dismissive commentary toward anyone trying to assist them. On 2/14/24, it was reported to Community Care Licensing that R1 was verbally aggressive with other residents and facility staff. The report goes on to relay that the resident stated, "The staff is defending a thief, R2 hates white people, and they will yell at them all R1 wants. The resident threatened the staff member stating R1 would report the staff member for defending a thief and a liar." LPA interviewed a resident council member, R3 and R3 stated that R1 was always yelling and being disruptive. R3 was present in the dining room on 12/15/24 and suggested contacting the local ombudsman for assistance with R1's behaviors. On 12/15/24 the incident report described R1 screaming at residents and staff in the dining room. The LIC 624 quoted R1 as stating, "You keep talking to the thief who stole from me and you should be in jail, you are a Nazi like the rest of them and telling everyone not to trust them." The Department finds the allegation,  "Resident was treated disrespectfully by medication technicians." to be UNSUBSTANTIATED. A finding of unsubstantiated means although the allegation may have happened or is valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided along with APPEAL RIGHTS. Exit interview.

Citations

No citations recorded on this visit

The inspector found no violations of California child care regulations during this visit.

FAQ · About this visit

Common questions about this visit

What happened during the June 4, 2025 inspection of LEGACY OAKS OF SACRAMENTO?

This was a complaint inspection of LEGACY OAKS OF SACRAMENTO on June 4, 2025. The inspection found no deficiencies and no citations were issued.

Were any citations issued to LEGACY OAKS OF SACRAMENTO on June 4, 2025?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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