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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342702896
Report Date: 09/16/2025
Date Signed: 09/16/2025 12:55:13 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
09/10/2025 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20250910090018
FACILITY NAME:LEGACY OAKS OF SACRAMENTOFACILITY NUMBER:
342702896
ADMINISTRATOR:JONATHAN AGUILARFACILITY TYPE:
740
ADDRESS:1922 MORSE AVENUETELEPHONE:
(916) 482-7745
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:160CENSUS: 84DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ashley Sylve TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff do not ensure the residents’ call buttons are always operational.
INVESTIGATION FINDINGS:
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On 09/16/2025, Licensing Program Analyst (LPA) Kimberly Varella made an unannounced visit to this facility to open this complaint investigation. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Ashley Sylve the Quality Assurance/Performance Improvement Director (RQAPID)/Designee and a brief interview followed.

Ombudsman (O1) was also present during this interview. The ED stated that they have been upgrading and repairing the call alert system in the building since 08/19/25. It went down on 08/19/25, and was back up on 08/22/25, however, the system has not been transmitting alerts as it was designed to and respresentatives from their IT department and the provider of the call system were working on resolving the issue. By 09/17/25, a final determination will be made regarding its ability to be 100% functional. If not, the ED shared that other systems have been evaluated and they will purchase one. This LPA learned that although the repairs for this system have been going on for almost a month, installing a new system might take up to 8 weeks.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 4
Control Number 27-AS-20250910090018
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: 09/16/2025
NARRATIVE
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In order to ensure services were provided, resident checks have been increased to once ever 2 hours or once every hour if the resident required it. Staff have been stationed in the hallways so that they may hear residents call for assistance. Bells and whistles have also be purchased to assist residents in alerting staff.

In addition, residents have been moved from one side of the building to the other. This was done for multiple reasons: so that repairs and remodels may be completed, to increase the efficiency of the air conditioning units during extreme heat, and to decrease the response time of carestaff.

Flyers were put up announcing the move on or about 09/05/25 and the move began on Monday, 09/08/25.
LPA and Ombudsman provided technical assistance on the importance of communicating with the residents and their responsible parties regarding resident moves and facility repairs.

The ED stated that a formal notice regarding the above information will be mailed out by the close of business on 9/16/25.

According to the California Code of Regulations, Title 22, the following regulation was violated:
87303 Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
(C) Identify the specific resident living unit.
This deficiency has been cited on the LIC 9099D page.

The ED stated that in the interim, they will relocate the alert system so that it may be physically monitored by staff and functional. The monitor will use walkie-talkies to communicate alerts to carestaff until the system is fully automated and functioning at 100%.

No other deficiencies were cited during today's visit, a copy of this report was provided and an exit interview was conducted with Ashley Sylve.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250910090018
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: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
87303(i)(1)
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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1)All facilities licensed for 16 or more... shall have a signal system which shall:

The licensee did not meet the above requirement when:
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The ED stated that in the interim, they will relocate the alert system so that it may be physically monitored by staff and functional. The monitor will use walkie-talkies to communicate alerts to carestaff until the system is fully automated and functioning at 100%.
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Based on observation and interview, the pendant /call alert system has not been functioning properly since 08/20/25. This posed/poses a potential risk to the health safety and personal rights of residents in care
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The ED will send pictures to Community Care Licensing showing the system in its new location and will provide a schedule of who will be monitoring the system. These photos and schedule will be provided by the close of business on 9/19/25
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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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4