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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 08/13/2025
Date Signed: 08/13/2025 03:01:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250522140000
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(559) 313-8062
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 87DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marlene BremerTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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On 08/13/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator/Executive Director. LPA met with Interim Director, Marlene Bremer and a brief interview followed.

Regarding the allegation: Staff are mismanging resident's medications.

This LPA reviewed the Electronic Medication Record (EMAR) for R1 from 03/01/25 - 05/04/25. The corporate regional nurse for this facility reviewed the symbols on the EMAR with this LPA. This PA observed an error on 04/13/25. There was a symbl logged for two of the the 5:00 PM medications passes (M1 and M2) that this LPA was told meant that the medication was packed up for the family to take with the resident when the resident left the building. However, there was another medication pass at 8:00 PM where it was indicated by a symbol, that another medication (M3) was not given becasue the resident was out of the building.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/13/2025
NARRATIVE
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The medication was not packed and sent out with the 5:00 PM medications. LPA requested the "Resident Leaves Report" which indicated that the resident left the building at 2:00 PM and returned at 11:10 PM. Even though the M3 was typically given at 8:00 PM, the doctor's instructions were, "TAKE ONE TABLET BY MOUTH AT BEDTIME." R1 retuned to the facility to go to bed and arrangements should have been made by the medication technician to ensure that R1 got their medication.

This deficiency has been cited on the LIC 9099 D page.

According to the California Code of Regulations Title 22, no other deficiencies were observed or cited during today's visit, 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: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250522140000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
87465(a)
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(a) A plan for incidental medical and dental care shall be developed by each facility.... routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
The Licensee did not meet the above requirement when:
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The Licensee stated that they will develop a plan so that residents who return after scheduled medication passes will still be administered their medications if it is still appropriate and safe to do so. This plan will be submitted to Community Care Licesning by the close of business on 8/14/25.
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Based on a review of the EMAR, R1 returned to the facility on the evening 4/13/25 and there was no plan in place to ensure that R1 was administered thier bedtime medication. This posed (poses) an immedicate risk to the health, safety and personl rights of 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3