Pricing ranges from
    $2,800 – 5,000/month
    1. Home
    2. Assisted Living
    3. California
    4. Sacramento

    Legacy Oaks of Sacramento

    1922 Morse Ave, Sacramento, CA, 95825
    3.7 · 64 reviews
    • Assisted living
    • Memory care
    For pricing and availability(510) 508-4507
    For the front desk(916) 482-7745
    AnonymousLoved one of resident
    3.0

    Friendly staff, inconsistent clinical care

    I placed my parent here and have mixed feelings: the staff are genuinely caring, activities are lively, meals tasty, and it's affordable and reasonably clean - she made friends and seemed happier. The building is dated with accessibility and safety quirks, and memory care has wandering risks. My biggest concerns are inconsistent clinical care - medication delays, poor handling of upset residents, spotty communication and occasional neglect reports. It can be a good value if you prioritize friendly staff, but visit several times and confirm staffing/medical oversight before deciding.

    Pricing

    $2,800+/moSemi-privateAssisted Living
    $3,100+/moStudioAssisted Living
    $3,600+/mo1 BedroomAssisted Living
    $3,500+/moSemi-privateMemory Care
    $5,000+/moSuiteMemory Care

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    3.66 · 64 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1

    • Care

      3.4

    • Staff

      3.8

    • Meals

      3.7

    • Amenities

      2.8

    • Value

      3.8

    Location

    Map showing location of Legacy Oaks of Sacramento

    About Legacy Oaks of Sacramento

    Legacy Oaks of Sacramento is a licensed Residential Care Elderly facility for people aged 55 and older, with 136 licensed beds offering a variety of living options, including shared bedrooms, studios, private rooms, and one-bedroom units, and they've got pet-friendly suites for those who want to keep their pets close by. The community accepts adults looking for long-term care and provides assisted living, memory care, nursing home, independent living, and continuing care retirement community services, with specialized care levels and associated fees for additional support, like an extra fee for a second person starting at $1,000 per month and specialized care costs ranging from $495 to $1,595 per month, though they can't take Medicare unless they're certified for it. Legacy Oaks has a memory care unit dedicated to residents with Alzheimer's or dementia, focusing on privacy, safety, and support, using personalized care plans that take into account each person's life story and abilities, while also respecting individuality and independence, and they've set up rooms and programs to reduce confusion and prevent wandering. They provide around-the-clock supervision with trained medical staff always present, who can help with medication, incontinence care, daily hygiene, and other activities of daily living, and they're licensed by the State, having passed surveys by local agencies like the Department of Aging or Veteran's Services.

    Legacy Oaks has daily activities managed by a Life Enrichment Coordinator, with a busy calendar featuring group fitness classes, social events, regular parties, a TV room with comfy sofas, scheduled companionship to bring people together, and meals served in a way to encourage conversation and reminiscing, alongside nutritious recipes using quality ingredients. Residents also benefit from memory care programs that honor personal histories and talents, supportive environment for those with memory impairment, and spaces tailored for both safety and comfort. Housekeeping, laundry, and trash removal services are routine, and staff strive to create a friendly, warm, and welcoming atmosphere focused on independence and well-being. Transportation and parking are available, and the community offers respite care for short-term stays too. Legacy Oaks of Sacramento, under new management and recognized for quality, continues to serve seniors and their families by providing reliable support, clear communication, and a secure home environment.

    People often ask...

    State of California Inspection Reports

    231

    Inspections

    65

    Type A Citations

    60

    Type B Citations

    6

    Years of reports

    11 Jul 2025
    Found no evidence that residents' bedding was dirty or not cleaned; inspections showed ample clean linens and clean bedding in observed rooms, with residents reporting weekly changes and staff confirming routine changes. Concluded the allegation unsubstantiated.
    04 Jun 2025
    Investigated and found that the wallet theft allegation could not be proven. The claim that a resident was treated disrespectfully by medication technicians was not supported by evidence.
    03 Jun 2025
    Found that staff did not provide prescribed medications to a resident, resulting in missed doses. Found that staff did not assist the resident with showers as scheduled.
    • § 87468.2(a)(1)
    • § 87465(a)(2)
    27 May 2025
    Investigated an incident in which a memory-care resident reported being slapped across the face; the home self-reported the incident and began an internal investigation with staff statements. No deficiencies were cited.
    • § 9058
    14 May 2025
    Found that an order excluding a staff member from access was served to the designated administrator; the staff member was not present and records were updated to remove them from the roster. The individual is not allowed to work, reside in, or have contact with clients in any licensed setting unless ordered by the department; no deficiencies were observed.
    • § 9058
    11 Dec 2024
    Found no deficiencies; staff clearances, resident and staff files, medication procedures, kitchen supplies, safety measures, and activity supervision were all in compliance.
    15 Nov 2024
    Identified that residents' dietary needs were not being met, with high-fat, high-sodium menu items and staff unaware of fat and sodium content. Found housekeeping services not consistently provided and some residents did not receive timely showers.
    • § 87464(f)(4)
    • § 87555(b)(7)
    • § 87555(b)(17)
    29 Oct 2024
    Investigated the allegation that staff refused to allow the resident to return. Found that the resident was returned on 10/25/24 after hospital care, so the claim was not supported.
    29 Oct 2024
    Identified multiple medication errors, including residents not receiving OTC vitamins due to missing prescriptions, unreported pharmacy changes, and outdated or missing medication lists. Found a deficiency for inadequate incidental medical care, specifically not ensuring assistance with self-administered medications.
    • § 87465(a)(4)
    11 Oct 2024
    Investigated the allegation of a questionable death and found insufficient evidence to prove improper care caused the death. Investigated the allegation that the resident did not receive appropriate medical care in a timely manner and found that care was not provided promptly.
    • § 87465(g)
    25 Sept 2024
    Found that the shared room of two residents was not cleaned on the scheduled twice-weekly basis, with multiple weeks showing missed cleanings. Noted safety concerns tied to a resident's medical condition that caused spitting and required staff cleanup, with occasional delays when staff attended to other residents.
    • § 87307(d)(2)
    • § 87303(a)
    26 Sept 2024
    Identified deficiencies in staff supervision of residents and in reporting incidents to licensing. Found failures to safeguard residents' personal possessions, inadequate assistance with dental care, and not informing the POA when medications were unavailable.
    • § 87217(b)
    • § 87465(a)(1)
    • § 87465(a)(2)
    26 Sept 2024
    Identified that the allegation that staff did not follow a physician's order was unfounded, since the resident did not obtain prior approval for the animal as required by policy.
    24 Sept 2024
    Found that staff cleaned a resident in a rough manner. Three staff confirmed that a specific caregiver did not provide proper care during cleaning and changing.
    • § 87468.2
    05 Sept 2024
    Identified the allegation of a high volume of Type A deficiencies, mainly in medical care, and noted ongoing concerns about resident care, safety, and relocation processes at the site.
    05 Sept 2024
    Identified high number of deficiencies and concerns, including resident care, activities, and fall prevention. Next steps include increased monitoring and follow-up meeting scheduled.
    15 Aug 2024
    Identified that an eviction notice was created on 03/15/2024 but mailed on 03/20/2024, failing to provide the required 30 days’ notice to the resident and their responsible party. Found that the resident frequently did not take medications as prescribed, with staff redirecting efforts and often notifying the licensed medical professional by fax, and incidents occurring across multiple locations within the home.
    15 Aug 2024
    Confirmed deficiencies in eviction process and medication management, but found no evidence to support allegations regarding care plan notifications or incident reporting.
    • § 87224
    08 Aug 2024
    Identified that a resident brought an unapproved dog into the community, breaching the admission agreement. The administrator explained the process for obtaining an emotional support animal, and the resident later returned to request an accommodation but left the office without comment.
    08 Aug 2024
    Identified violation of bringing unauthorized animal into facility. Resident agreed to remove the dog after discussion with administrator.
    25 Jul 2024
    Identified that one resident required total assistance with multiple daily activities, including 2-person transfers, and sustained 23 unwitnessed falls between 3/11/2023 and 4/14/2024. Found that fall-prevention measures like floor mats and one-to-one sitters were not clearly reflected in the resident's fall-prevention approach, that outside paramedic lift services were used, and that one-to-one care was needed to prevent falls.
    25 Jul 2024
    Determined that the resident's multiple falls were due to lack of supervision, with records showing numerous hospital visits for falls during the stay. Found that the claim that staff did not seek timely medical attention after a fall and the claim that staff did not meet hydration needs were not supported by the evidence.
    • § 1569.312(e)
    25 Jul 2024
    Identified multiple falls and inadequate fall prevention measures for a resident that required extensive assistance with daily tasks.
    • § 87405(h)(5)
    • § 87411(a)
    23 Jul 2024
    Found insufficient evidence to prove the allegation that a resident's clothes were removed from the room without consent. The investigation, including interviews and record reviews, could not determine who removed the clothes.
    23 Jul 2024
    Confirmed that residents' clothing was moved without consent, but insufficient evidence was found to prove or disprove the allegation.
    17 Jul 2024
    Found insufficient evidence to support the allegation that staff failed to ensure residents received showers while in care. Found insufficient evidence to support the allegation that staff left a resident in soiled diapers while in care.
    17 Jul 2024
    Reviewed allegations of staff not ensuring residents received showers and leaving residents in soiled diapers, ultimately finding insufficient evidence to support the claims.
    08 Jul 2024
    Determined that the allegation of residents eloping due to lack of supervision did not meet the preponderance of evidence. Found no deficiencies were observed; interviews and incident records showed residents were supervised and exits occurred only with staff, including one-on-one caregivers.
    08 Jul 2024
    Investigated an allegation of residents eloping from the facility but found no evidence to support the claim. No deficiencies were found during the visit.
    05 Jul 2024
    Investigated two specific allegations: staff did not meet residents' toileting needs and staff did not ensure residents were adequately fed, with prior evidence of ongoing care concerns; today, no deficiencies were observed.
    05 Jul 2024
    Confirmed deficiencies in care for residents during a recent inspection.
    03 Jul 2024
    Determined that the allegation that staff did not report an incident to the licensing agency as required for mandated reporters occurred. Found no evidence supporting the allegations that residents were humiliated, that their privacy was violated, or that their dignity was compromised.
    03 Jul 2024
    Confirmed that facility did not report an incident as required and found allegations of abuse and privacy violations to be unsubstantiated.
    • § 87211(a)(1)
    13 Jun 2024
    Found that the claim of disrepair did not occur, based on several unannounced checks showing clean and well-maintained rooms. Found that the claim that resident rooms were not kept clean was not proven, as three random units were clean and staff reported regular cleaning; no deficiencies were observed.
    14 May 2024
    Investigated the complaint and found the allegation in this case unsubstantiated after interviews and document reviews. No deficiencies were identified.
    14 May 2024
    Unsubstantiated complaint, no deficiencies observed.
    13 May 2024
    Found that in 2023 a caregiver used a resident's debit card for personal purchases; authorities and the ombudsman were notified, and the resident did not want to press charges. No deficiencies were observed during this visit.
    13 May 2024
    Identified an incident where a caregiver used a resident's debit card for personal purchases and took appropriate disciplinary action. No deficiencies were cited during the visit.
    03 May 2024
    Found no evidence of a centrally stored medication log for 10/23/23 through 12/23/23 and that several residents did not receive their scheduled showers. Found meals not appropriate for residents' needs, while linens were observed as clean.
    03 May 2024
    Substantiated findings included improper maintenance of centrally stored medications and inadequate showering frequency for certain residents. Other allegations, such as unqualified staff administering insulin and lack of activities for residents, were determined to be unfounded or unverified.
    • § 87555(b)(5)
    • § 87465(a)(6)
    • § 87464(f)(4)
    01 May 2024
    Investigated eviction notice sent to a resident's conservator and found it did not include the supporting materials referenced. Department cited administrator qualifications.
    01 May 2024
    Confirmed a substantiated allegation regarding a lack of supporting evidence provided with an eviction letter.
    • § 87405(d)
    23 Apr 2024
    Identified illegal eviction due to differences between the eviction letter sent to the designated representative and the version reviewed, including a misdated mailing date, a missing line about good cause, and omission of attached documents; no other deficiencies were observed.
    03 Apr 2024
    Investigated found the eviction letter sent to the resident’s POA differed from the draft in three ways: the mailing date, a line about attached Exhibits, and missing Exhibits A–L. The missing attachments and incomplete details led to the unlawful eviction allegation being identified, and no other deficiencies were observed.
    23 Apr 2024
    Identified that a pre-appraisal was not completed prior to a resident's application and initial move. The resident was moved to Memory Care within a short period due to behavioral needs.
    • § 87457(a)
    23 Apr 2024
    Identified deficiencies in eviction procedures during the visit.
    • § 87224
    16 Apr 2024
    Determined that the allegation that a resident was not allowed to return to the community after hospital discharge occurred, despite the resident's right to return.
    16 Apr 2024
    Confirmed the allegation that a resident was not allowed to return to the facility after being discharged from the hospital.
    • § 87724(b)
    03 Apr 2024
    Found that the claim the phone was inoperable was not supported; the phone system was operable but inefficient, with a single incoming line and voicemail delays.
    03 Apr 2024
    Identified that the allegation of staff sleeping during overnight shifts was true and determined that despite inefficiencies, the facility phone was not inoperable.
    • § 1569.312(a)
    27 Mar 2024
    Found that a resident punched another resident in the dining area around 11:00–11:30 AM; staff intervened and the aggressor was transported to the hospital, with police notified. The other resident declined further medical evaluation; eviction papers were served, and no deficiencies were cited.
    27 Mar 2024
    Identified a resident on resident altercation, where one resident assaulted another, prompting intervention from staff and calls to emergency services.
    20 Mar 2024
    Identified the allegation that staff violated residents' personal rights by not allowing medical assistance. A resident with a bloody, itchy rash requested emergency transport but was not transported; the ambulance arrival and related actions were not documented.
    20 Mar 2024
    Confirmed that staff did not allow a resident to get medical assistance for a rash, leading to the allegation being substantiated.
    • § 87465(a)(1)
    18 Mar 2024
    Found that the allegation that staff did not allow family visitation was unfounded; records showed visitors could visit at any time and after-hours visits could be arranged.
    18 Mar 2024
    Found that allegations about restricting visitation at any time were unfounded due to visitors being allowed to come at any time, with exceptions made for specific cases.
    29 Feb 2024
    Found limited activities during several unannounced visits, with schedules showing a sharp decline in programs and no new activities in a long time. Identified a deficiency related to planned activities and the staff responsible for organizing and supervising them, amid ongoing vacancies in the activities leadership role.
    22 Feb 2024
    Found that the allegation that a resident was denied visitation from a visitor was unsubstantiated. No deficiencies were found.
    29 Feb 2024
    Reviewed activities schedule and found a decrease in frequency and type of activities offered for residents. Staffing issue resulted in lack of full-time Activities Director.
    • § 87217(f)
    27 Feb 2024
    Identified that two residents with aggressive histories were moved between memory care and other areas without proper reappraisals, and that smoking near the building contributed to safety concerns. Found that incident reports were not sent to licensing and that prior leadership failed to ensure appropriate interventions, with civil penalties assessed.
    27 Feb 2024
    Identified deficiencies in resident care and safety led to civil penalties being assessed.
    • § 87405(h)(5)
    22 Feb 2024
    Found on-site review showed staff were assisting residents with meals, reviewing care notes and medication records, and interviewing staff about a prior resident altercation. No deficiencies were observed today, and a return visit was planned to finalize findings.
    22 Feb 2024
    Found allegation of declining visitation to be unsubstantiated after additional information and interviews were conducted. No deficiencies observed during visit.
    21 Feb 2024
    Found no deficiencies during the visit. Noted ongoing staff trainings, a planned interview for an activities director, and new contracts for a smoking area and linen service, with updated staff records and background checks reviewed.
    21 Feb 2024
    Found that staff did not provide adequate supervision to residents during the period reviewed, based on interviews and scheduling records.
    21 Feb 2024
    Confirmed lack of adequate supervision due to staffing issues, resolved through increased staffing ratios.
    • § 87411(a)
    16 Feb 2024
    Determined that staff did not meet residents’ toileting needs and that a resident was not adequately fed, while supervision remained adequate and the call system was functioning properly.
    • § 87464(f)1
    16 Feb 2024
    Identified concerns that staff did not meet residents' hygiene needs. Identified concerns that staff did not provide adequate food service.
    15 Feb 2024
    Found that a resident was left in soiled clothing for an extended period, based on interviews and observations.
    • § 87625(b)(3)
    16 Feb 2024
    Confirmed inadequate hygiene care and food service for residents based on observations and interviews. Citations issued and appeal rights provided.
    • § 1569.312(a)
    • § 87464(f)(4)
    15 Feb 2024
    Identified concerns that two residents with aggression histories were inappropriately matched as roommates and that related incidents were not adequately documented or addressed, with insufficient care and supervision. Noted that one resident had not received a re-appraisal after moving to memory care.
    15 Feb 2024
    Identified an altercation between two residents that resulted in physical harm, leading to concerns about their pairing as roommates and lack of appropriate supervision.
    • § 87462
    • § 87705(b)(2)
    06 Feb 2024
    Found three staff members lacked required health screenings on file: one resigned before the due date, another's 2/1/24 screening did not include a tuberculosis test or chest X-ray, and a third screening was not provided. Imposed civil penalties totaling $400 for 2/3/24 through 2/6/24 for failure to correct, with potential for more penalties if the deficiency remains; no deficiencies were cited this visit.
    06 Feb 2024
    Identified deficiencies in staff health screenings resulted in a civil penalty being assessed for failure to correct.
    01 Feb 2024
    Identified the allegation that staff did not respond to call alerts within the 5-7 minute target and found one alert unit malfunctioning. Reviewed January call logs showing many alerts exceeded the target response time, thereby supporting the allegation.
    02 Feb 2024
    Found that staff did not answer the main telephone line as alleged. Interviews and observations showed calls often did not connect, were not transferred, and voicemail was unavailable due to full mailboxes, leading to missed messages.
    02 Feb 2024
    Confirmed allegation that staff did not answer phone calls.
    • § 87468.1(a)(14)
    01 Feb 2024
    Confirmed that staff at the facility did not meet the expected response time for call alerts.
    • § 87303(i)(1)
    24 Jan 2024
    Investigated an allegation that three staff members were missing health screenings on file and noted a resident diagnosed with dementia. Found medications securely stored, adequate food supplies, and temperatures within required ranges.
    24 Jan 2024
    Identified deficiencies in health screenings and documentation. Residents and staff were interviewed during the inspection.
    • § 87705(c)(5)
    • § 87411(f)
    17 Jan 2024
    Found that the allegation that the building was not kept odor-free because the back door was propped open, allowing cigarette smoke inside, was supported. Residents and staff reported smelling smoke, and prior visits had noted the door propped open.
    17 Jan 2024
    Confirmed smoking policy violation inside the building.
    • § 87468.1(a)(2)
    11 Jan 2024
    Found memory care to be malodorous throughout; the assisted living portion was not malodorous, and no activities were observed. Identified a deficiency regarding keeping incontinent residents clean and dry and preventing odors from incontinence, and will return later to complete the case management.
    • § 87625(b)(3)
    11 Jan 2024
    Found that incidents were not reported to Community Care Licensing. Found that residents were not sent out for medical evaluation when behavior changes occurred, and supervision lapses created unsafe conditions, including access to dangerous items and an unmonitored room.
    11 Jan 2024
    Confirmed deficiencies in reporting incidents, sending residents for medical evaluation, and supervising residents in care.
    • § 87705(f)(1)
    • § 87211(a)(1)
    • § 87465(a)(1)
    10 Jan 2024
    Found that staff did not ensure residents' rooms were cleaned. Observations noted room #33 had a dirty adult brief and a malodorous memory care area, and room #52 contained moldy food in the microwave and a dirty shower with items left on the floor; housekeeping schedules showed ongoing cleaning of all areas.
    10 Jan 2024
    Identified cleanliness concerns in the home, including a dirty room and malodors in the memory care area, despite ongoing housekeeping and pest-control services. Privacy-related allegations were not demonstrated based on interviews and observations.
    10 Jan 2024
    Reviewed training records for five staff members at a care setting and identified that three of three medication technicians had not completed the required med tech training. Citations were issued; an exit interview was conducted with the executive director, and appeal rights were provided.
    • § 1569.69(a)(1)
    10 Jan 2024
    Identified that residents’ medications were not administered as needed because several meds were unavailable for multiple days and there was no documented effort to obtain refills. Determined that staff training hours and topics did not meet required standards, and observed a dirty item in one resident room despite ongoing housekeeping and pest control.
    • § 87465(a)(4)
    • § 87303(a)
    • § 1569.625(b)
    10 Jan 2024
    Confirmed that staff did not ensure resident rooms were cleaned properly, as evidenced by dirty and malodorous conditions observed in certain rooms despite a regular housekeeping schedule.
    21 Dec 2023
    Identified multiple deficiencies, including improper administration and documentation of medications, failure to dispose of medications no longer needed, and missing or inaccurate discharge instructions after hospital visits; a high-fall-risk resident did not have bathroom grab bars, contributing to injuries. Alleged that staff did not respond promptly to resident call bells, failed to safeguard personal belongings, and did not consistently follow reporting requirements for unusual incidents.
    21 Dec 2023
    Confirmed multiple allegations including improper medication administration, failure to respond to resident calls for assistance, and inadequate safeguarding of personal belongings. Unsubstantiated reporting of unusual incidents.
    • § 87211(a)(1)
    • § 87218(a)
    • § 87303(e)(4)
    • § 87411(d)(3)
    • § 87465(i)
    • § 87468.2(a)(1)
    • § 87465(a)(4)
    05 Dec 2023
    Found that a caregiver secretly recorded residents on video with inappropriate comments, and leadership did not respond promptly; the caregiver was terminated, police involvement occurred, and exclusion letters were issued to the caregiver and to facilities she was connected with.
    12 Dec 2023
    Determined that the allegation that staff did not provide the resident's authorized representative with the resident's records in a timely manner is unsubstantiated. No deficiencies were cited.
    12 Dec 2023
    Investigated a complaint alleging failure to provide a resident's authorized representative with records in a timely manner; determined the allegation lacked sufficient evidence to support it.
    06 Dec 2023
    Found occasional roach sightings reported by residents, with an active pest-control program providing timely treatments. Interviews indicated no ongoing infestation, and no deficiencies were observed.
    06 Dec 2023
    Investigated an allegation of pests and found no infestation, with effective pest control measures in place and neither residents nor staff perceiving a significant problem.
    05 Dec 2023
    Confirmed allegation of inappropriate behavior by an employee towards residents through video evidence.
    • § 87468.2(a)(8)
    09 Nov 2023
    Identified a high volume of deficiencies over the past 18 months and multiple issues, including inadequate oversight and staffing, training gaps, concerns about incidental medical care and residents’ personal rights, and reporting weaknesses. The regional office will maintain increased monitoring and may pursue further action if noncompliance continues.
    21 Nov 2023
    Investigated multiple care-related complaints and identified odor problems in some resident rooms and concerns about residents being treated with dignity and respect. Other issues—piles of dirty laundry, dinner provision, call pendant responsiveness, and PRN medication access—had limited support.
    21 Nov 2023
    Confirmed allegations of residents not being provided with dignity and respect due to malodorous rooms, unresponsive pendant calls, and delayed medication delivery.
    • § 87303(i)(1)
    • § 87465(b)
    • § 87307(d)(2)
    • § 87468.1(a)(2)
    15 Nov 2023
    Identified a safety hazard in room 16 where laminate flooring was peeling from concrete, creating a tripping risk, with deficiencies noted under state regulations.
    15 Nov 2023
    Identified deficiency in facility maintenance that posed health and safety risk.
    • § 87303(a)
    09 Nov 2023
    Conducted an unannounced case-management visit to serve an exclusion letter to a resident; attempts to contact by phone were made, access was provided by a building resident, and the letter with related documents was sent by certified mail.
    09 Nov 2023
    Identified deficiencies in care, staffing, training, and resident rights during a recent meeting. Monitoring and follow-up actions planned for compliance.
    • § 9111
    08 Nov 2023
    Identified that a resident who moved from assisted living to memory care required a re-evaluation and a new LIC 602, which had not been completed. Incidents of aggressive behavior occurred on 11/01/23 and 11/05/23, the administrator attempted to contact the power of attorney to obtain the new LIC 602, and a deficiency was cited under state regulations.
    08 Nov 2023
    Conducted a case management visit at this site, met with a vice president of operations, and held a brief interview. Served an Immediate Exclusion letter to the official and completed an exit interview.
    08 Nov 2023
    Found deficiencies in the care provided to a resident who needed to move to a different level of care within the facility. A new assessment and plan were required but were not completed.
    • § 87463(c)
    03 Nov 2023
    Identified that a staff member posted a video of three residents on social media without consent, prompting police involvement. Interviews were conducted with staff and residents; two residents appeared unaware of the recording, and no deficiencies were cited.
    03 Nov 2023
    Investigated an incident involving a staff member who allegedly posted a video of residents on social media. Conducted interviews and reviewed relevant documentation; ongoing investigation with no deficiencies identified during the visit.
    24 Oct 2023
    Identified four employees who were background cleared but not associated with this site.
    24 Oct 2023
    Identified a violation of regulations regarding background checks for employees during the visit.
    • § 87355(e)(2)
    06 Oct 2023
    Found no conclusive evidence that the air conditioning system was malfunctioning, with maintenance records showing regular service and temperatures kept within an acceptable range. Identified no regular consultation from a registered dietitian for the kitchen and no written records of visits, and found staffing shortages that contributed to medication delays for several residents.
    06 Oct 2023
    Substantiated allegations regarding the lack of qualified staff in the kitchen and insufficient staffing to meet the residents' needs.
    • § 80072(a)(2)
    • § 87555(17)
    20 Sept 2023
    Found that staff did not administer medications as prescribed, with incomplete July–August MARs and residents reporting they did not receive their medications.
    20 Sept 2023
    Confirmed that staff did not administer medications as prescribed, resulting in a substantiated complaint and issuance of a civil penalty.
    • § 87465(a)(1)
    06 Sept 2023
    Identified the Personal Rights allegation as supported; records showed the resident was bedridden and required repositioning every two hours, while staff claimed the resident did not need repositioning.
    06 Sept 2023
    Confirmed that the facility did not fully meet the resident's needs as outlined by their physician and service plan, with documentation inconsistencies regarding required repositioning care.
    • § 87465(a)(1)
    07 Jul 2023
    Found no evidence supporting an air conditioning issue or a cigarette smoke odor; no deficiencies cited.
    07 Jul 2023
    Confirmed that the air conditioning system was working properly but did not find evidence of cigarette smoke odor in the facility.
    23 Jun 2023
    Identified issues with staff mishandling resident medications and MAR documentation after interviews and record reviews. Allegations of money theft, spoiled meals, and pests were not supported, as most residents reported no concerns and observations showed generally clean conditions.
    23 Jun 2023
    Found the administrator's certificate had expired and was later recertified; the department will continue to recognize the administrator until the certificate is obtained. Noted a request to inform and provide a copy when obtained.
    23 Jun 2023
    Confirmed mishandling of medication was unsubstantiated, while improper documentation of medication administration was substantiated. Concerns about stolen money, spoiled meals, and pest control were also unsubstantiated.
    • § 87465(d)(3)
    20 Jun 2023
    Found two residents in wheelchairs outside before entry with no staff supervision, while physician reports showed they could not leave unassisted. Identified the need for staff supervision whenever residents who cannot leave unassisted exit.
    • § 87468.2(a)(4)
    20 Jun 2023
    Found that a blouse caught fire in a dryer in the laundry area on 6/17/23; staff extinguished it with two extinguishers, the alarm sounded, and all residents evacuated safely until clearance by the fire marshal. Sacramento Metro Fire Department required an earlier reinspect of the alarm, which was inspected and cleared on 6/19/23; no deficiencies were cited.
    20 Jun 2023
    Inspected facility following small fire incident with no deficiencies cited. No threats to health and safety of residents identified.
    08 Jun 2023
    Found two previously cited deficiencies cleared and due dates met, with a clearance letter issued. Observed a two-day supply of nonperishable food, reviewed updated administrator qualifications, and conducted an exit interview.
    08 Jun 2023
    Confirmed deficiencies have been corrected within the specified timeframe.
    31 May 2023
    Determined the rate increase allegation regarding the admission agreement was unfounded and dismissed, with evidence showing the resident’s rent did not increase; no deficiencies were noted.
    31 May 2023
    Allegation of failure to follow admission agreement regarding a rate increase was investigated and found to be unfounded. No deficiencies were noted.
    16 May 2023
    Found that the prior deficiency related to storing perishable foods in two freezers was corrected by the due date. Identified noncompliance for failing to notify the department about an administrator change and for not obtaining approval, with the administrator certificate expired and not properly posted.
    16 May 2023
    Identified deficiencies in food storage and lack of proper notification regarding an administrator change during the inspection.
    • § 87405(f)
    • § 87555(b)(26)
    09 May 2023
    Identified a broken walk-in freezer, frozen produce stored in a vacant resident refrigerator for 90 residents, and pork loins and diced ham cubes discarded due to insufficient freezer space after delivery on 05/06/2023.
    09 May 2023
    Found deficiencies in food storage, including storing frozen produce in a resident's refrigerator and having to discard items due to lack of freezer space.
    • § 1987
    12 Jan 2023
    Found the site clean and well maintained, with adequate lighting, required furniture, and working safety systems, and medications, toxins, and sharps stored locked. Found water at 109 degrees Fahrenheit within the 105–120 range, adequate seven-day non-perishable and two-day perishable food supplies, entry screening with Covid-19 signage posted, and the ability to designate a Covid-19 room if needed; no deficiencies cited.
    12 Jan 2023
    Inspection found no deficiencies and facility was in compliance with regulations regarding safety, cleanliness, and Covid-19 protocols.
    03 Jan 2023
    Found residents were provided 2-3 rolls of toilet paper weekly, though one resident ran out. Found adequate staffing and that residents' needs were met; however, one resident waited over an hour for assistance, and medication administration raised concerns due to unsigned MARs and the resident reporting not receiving meds; hot meals were delivered in hot trays and could be reheated, and this hot meals allegation was not supported.
    03 Jan 2023
    Confirmed allegations of insufficient toilet paper provided to residents and failure to administer medication, while allegations of inadequate staff responsiveness and food temperature were unsubstantiated.
    • § 87468.1(a)(2)
    • § 87464(f)(4)
    29 Dec 2022
    Found that the allegation that staff did not feed a resident was unsubstantiated; meals were delivered to the resident’s room and the resident stayed there during mealtimes. Found that the allegations that staff did not shower the resident for an extended period and that bed linens were not changed for an extended period were unsubstantiated; the resident refused several showers, there is an AM/PM shower schedule, linens are changed during showers when possible, and staff were present though staffing was short.
    29 Dec 2022
    Confirmed that food was delivered to the resident's room, a regular shower schedule was maintained despite the resident's refusal, bed linens change attempts were blocked by the resident's refusals, and staff were present but faced short-staffing issues; however, no conclusive evidence to support the allegations was identified.
    13 Dec 2022
    Investigated five specific allegations: insufficient staffing to meet resident needs; smoking area provided for residents is not safe for wheelchair access; wheelchair residents cannot gain access through the door; staff refused to assist a resident upon request; and staff did not inform the resident's authorized person of illness. Based on interviews and observations, there was not enough evidence to prove these violations occurred.
    13 Dec 2022
    Reviewed allegations including insufficient staffing, unsafe smoking area, access issue for wheelchair residents, staff refusal to assist, and failure to inform authorized person of resident illness. No evidence found to support the allegations.
    06 Dec 2022
    Found five specific allegations unsubstantiated: staff did not assist with meal services as necessary; staff did not adequately manage medications; did not ensure medications were administered per physician instructions; did not ensure the resident's room was clean; and did not ensure the resident had clean laundry. Determined that the preponderance of evidence did not support these violations.
    06 Dec 2022
    Found no evidence to support allegations of staff failing to assist with meal services, manage medications, maintain a clean room, or provide clean laundry for a resident.
    07 Nov 2022
    Identified that a resident's catheter bag was not emptied promptly, remaining full during the PM shift and emptied by the AM shift. Found that residents received 2-hour checks and were not left in a soiled condition; residents reported no threats by staff, and rooms were observed to be clean and sanitized.
    07 Nov 2022
    Confirmed staff are meeting residents' bathroom needs and administering medications properly, but found a substantiated allegation of staff not emptying a resident's catheter bag. No evidence of staff threatening residents or neglecting to clean rooms.
    • § 87623(b)(2)
    01 Sept 2022
    Investigated and found insufficient evidence to prove that the resident’s linens were not changed promptly because caregivers waited for EMS during an emergency. Identified cockroaches in the resident’s room, observed by the resident and their daughter.
    01 Sept 2022
    Confirmed that linens were soiled due to a caregiver waiting for EMS before changing them, and identified insects in a resident's room.
    • § 87307(d)(2)
    12 May 2022
    Found cockroaches in one room. Other allegations, including physical abuse, aggressive pushing, being spoken to inappropriately, untimely medical attention, medication issues, feeding residents unsanitary food, and rats, were unsubstantiated.
    12 May 2022
    Confirmed physical abuse allegations unsubstantiated. Cockroach presence substantiated. Other allegations unsubstantiated.
    • § 87307(d)(2)
    11 May 2022
    Found that a resident sustained multiple fractures while in care, with staff witnessing a fall. Found that the conservator was not informed about changes in the resident's condition and that medical attention was not sought promptly.
    11 May 2022
    Confirmed multiple fractures sustained by resident, lack of communication with conservator, and delayed medical attention. A civil penalty was issued.
    • § 87211(a)(2)
    • § 87465(j)
    • § 87464(f)(1)
    26 Apr 2022
    Found staff provided two-hour checks and assisted with incontinence care, and monitored oxygen to ensure it stayed operable. Observed a room that was not clean and sanitary, with to-go boxes and cups, and noted a medication handling concern.
    26 Apr 2022
    Confirmed allegations of staff mishandling resident's medication, but found insufficient evidence to support other claims.
    • § 87211(a)(2)
    • § 87465(j)
    • § 87464(f)(1)
    14 Mar 2022
    Determined there was no evidence to support the allegation that staff did not follow the resident's care plan or that the resident's personal hygiene needs were neglected, as daily skin checks were performed and dentures were cleaned nightly. Determined there was no evidence of understaffing or inadequate food services, with shifts covered when needed and meals and snacks provided on schedule.
    14 Mar 2022
    Monitored resident's skin condition daily and met personal hygiene needs by cleaning dentures nightly. Staffing levels maintained despite one call-off. Adequate meals provided throughout the day.
    • § 87303(a)
    14 Feb 2022
    Identified that staff wore masks, residents maintained social distancing during meals, PPE supplies were stocked, and hygiene signs were posted; employee and visitor logs were complete and monthly trainings occurred. A Change of Ownership notice was provided to residents, vaccination and testing rules for visitors were in place, and no deficiencies were cited.
    14 Feb 2022
    Found that only Med-Techs dispense medications and follow the MAR schedule, with training logs and staff associations confirming this, and that residents and staff report no problems with dispensing. Found no evidence of mismanagement or disrespect toward residents, with residents stating they are treated well and not verbally abused; allegations unsubstantial.
    14 Feb 2022
    Confirmed no deficiencies during the visit. Residents and staff observed following COVID-19 guidelines.
    08 Feb 2022
    Investigated findings showed that a staff member mishandled a resident's medication by retrieving it from the pharmacy, giving it to the resident without logging it in, and leaving the site, later returning to report the incident.
    • § 87465(h)(2)
    08 Feb 2022
    Confirmed mishandling of resident's medication by staff during care.
    03 Feb 2022
    Found no deficiencies and noted compliance with safety measures, including proper water temperature, adequate food supplies, current fire safety equipment, carbon monoxide detectors, locked medications, and infection-control practices. Observed central entry screening and sign-in procedures with routine symptom checks for staff, residents, and visitors.
    03 Feb 2022
    Found readiness for licensure after an unannounced pre-licensing check. Water temperatures in resident bathrooms were within the required range, carbon monoxide and smoke detectors were present, medications and cleaning supplies were securely stored, and living and sleeping areas were clean and well lit.
    03 Feb 2022
    Inspection conducted, facility found to be in compliance with regulations.
    03 Feb 2022
    Inspection confirmed compliance with health and safety regulations at the facility.
    06 Jan 2022
    Confirmed that a change of ownership for a 160-capacity elderly residential care operation with 54 residents was reviewed, and that the applicant and administrator demonstrated understanding of licensing rules during a COMP II interview, with LIC 809 and photo ID obtained. Identified that this understanding covered license type, resident populations, programs, admissions policies, staffing and training, restrictive/prohibited health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
    06 Jan 2022
    Confirmed understanding of regulations and operational requirements during a change of ownership inspection.
    19 Nov 2021
    Found no deficiencies during the visit. Observed proper PPE use, handwashing and distancing signs, complete logs, and visitor rules based on vaccination or testing status.
    19 Nov 2021
    Conducted unannounced inspection, observed staff following COVID-19 protocols, no deficiencies cited.
    04 Nov 2021
    Identified Neglect/Lack of Supervision as having occurred after noting delays in PRN pain medication, extended waits for feeding assistance, and rooms with trash and soiled diapers left unattended due to staffing shortages.
    04 Nov 2021
    Found issues with delays in administering medication and inadequate staffing affecting resident care, but the evidence was not sufficient to substantiate allegations of neglect or lack of supervision.
    01 Nov 2021
    Identified medication administration documentation and diet plan issues, including missing staff signatures on MARs for several medications on multiple dates, unadministered meds due to refill gaps, and pureed meals served without proper diet orders or specifications for multiple residents.
    01 Nov 2021
    Reviewed medication administration issues, incontinence care, and dietary needs at a care facility; dietary plans not followed, but feeding and incontinence care issues lacked sufficient evidence.
    29 Oct 2021
    Found that a resident’s prescribed medication disappeared around 9/18/21 with no MAR documentation, and MAR entries showed a sign-off for medication that was not provided on at least one occasion, along with a fall on 9/25/21 and related incident not reported to the appropriate authorities. Found that other claims regarding staff interactions, handling of injuries, and inappropriate comments lacked sufficient evidence, and noted that some staff may sleep in resident rooms; no citation was issued at that time.
    29 Oct 2021
    Found missing medication, unreported incident, and staff living in resident rooms. Inappropriate staff conduct allegations not substantiated.
    28 Oct 2021
    Investigated the pest-related allegation and found no evidence the violation occurred.
    28 Oct 2021
    Found that the allegations of pests, room temperatures, and staff response were unsubstantiated.
    • § 87465(h)(2)
    • § 87211(a)(2)
    27 Oct 2021
    Identified Neglect/Lack of Supervision allegation; observed the memory care unit's emergency alert system was deactivated, potentially delaying staff response to residents. Interviews with residents and staff did not identify unmet needs or delays in services, though some staff noted occasional staffing shortages.
    27 Oct 2021
    Determined the odor allegation could not be proven after on-site checks and resident interviews; three residents denied observing a bad odor, and staff confirmed pest treatment and removal of animals. No deficiencies identified.
    27 Oct 2021
    Confirmed allegations regarding a deactivated signal system in the memory care unit. Unsubstantiated allegations of neglect/lack of supervision due to lack of evidence from interviews and observations.
    • § 87411(a)
    26 Oct 2021
    Identified an unassessed, unstaged pressure injury in a resident, with no wound care or medical assessment, leaving the injury stage undetermined. Exit interview conducted and appeal rights provided.
    26 Oct 2021
    Identified unassessed pressure injury in a resident during a case management visit.
    25 Oct 2021
    Identified several deficiencies, including a locked bathroom preventing use, ceiling leaks with a resident relocation and furniture move, overflowing trash and bins not emptied on multiple days, missing soap, an unsanitary toilet, a washer broken for 10 days, and hallway bathroom trash bins without toilet seat covers.
    25 Oct 2021
    Identified deficiencies in various areas, including locked bathroom doors, ceiling leaks, overflowing trash cans, lack of soap, unsanitary toilets, and broken appliances.
    • § 7465
    20 Oct 2021
    Identified that the admission agreement included a signed addendum documenting receipt of the resident handbook and indicating a signal system is available in all resident rooms. Found the memory care unit's emergency pull cords in bathrooms were deactivated and not reset, with cords pulled indicating a need for staff assistance.
    • § 87303(i)(1)
    • § 87507(f)
    20 Oct 2021
    Confirmed deficiency found in the admission agreement regarding the signal system in resident rooms.
    • § 87458(b)(4)
    • § 87465(a)(5)
    • § 87464(f)(3)
    06 Oct 2021
    Found that staff and an administrator resided in a designated resident room four days a week, and that conditions were not in good repair, with hazards including a glove on the floor, a broken fountain, and overgrown shrubs blocking an exit. Identified a leaking faucet in room 57, a dead cockroach in room 43, and dust and dead bugs under a resident's bed, indicating noncompliance with Title 22 regulations.
    06 Oct 2021
    Identified deficiencies in maintenance, cleanliness, and staff conduct during the visit.
    01 Oct 2021
    Investigated the allegation that a resident's medication was mismanaged. The resident denied the allegation, and medication logs plus staff interviews showed no evidence to prove the violation.
    01 Oct 2021
    Reviewed an allegation of medication mismanagement but found no evidence to prove it occurred.
    • § 87303
    07 Sept 2021
    Investigated medication administration timing and COVID-19 precaution practices; substantiated a COVID-19 related allegation and identified inconsistencies in medication timing documentation.
    07 Sept 2021
    Identified concerns with medications and lack of proper Covid-19 precautions during recent inspections.
    • § 87208(a)(7)
    • § 87303
    23 Aug 2021
    Found no clear evidence of staffing shortages. Found the AC was broken and being repaired; records showed long call-button response times, and residents had access to water.
    • § 87464(f)(4)
    23 Aug 2021
    Found that a resident left the premises unassisted on 8/10/2021, was later found in a park, and stated they did not want to return. During an unannounced case management visit on 8/23/2021, deficiencies were cited related to that incident and appeal rights were provided to the administrator, with an exit interview conducted.
    23 Aug 2021
    Identified deficiencies during a visit related to a resident leaving the facility without permission.
    11 Aug 2021
    Found no deficiencies cited after a remote case management that included a virtual tour and discussions on cleaning, PPE use, cohorting, staffing, dining procedures, visitation, and infection control.
    11 Aug 2021
    Inspection on 08/11/2021 with no deficiencies cited. Various topics on infection control and facility operations discussed during the visit.
    • § 1569.2(c)
    28 Jul 2021
    Investigated Covid-19 compliance and ownership-related concerns, identifying staff not wearing masks, improper donning and doffing of PPE, missing masking and social distancing signage, an inaccurate mitigation plan, and allegations of change of ownership and licensee abandonment; noted that no deficiencies were cited during this visit.
    28 Jul 2021
    Identified multiple deficiencies related to non-compliance with Covid-19 regulations and reporting requirements.
    26 Jul 2021
    Found the allegation that staff failed to seek timely medical attention resulting in a resident's death unfounded. Found the allegation that staff failed to seek timely medical attention during a power outage when the resident's air supply ran out unfounded.
    26 Jul 2021
    Investigated allegations of staff failing to seek timely medical attention during a power outage and confirmed they were false; resident remained on oxygen and did not run out.
    23 Jul 2021
    Identified the allegation that Covid-19 cases were not reported promptly and that a positive Covid-19 line list and compliance with the mitigation plan were not provided. Noted a civil penalty for a repeat violation within 12 months.
    23 Jul 2021
    Cited deficiencies were observed during a virtual visit in response to reported positive Covid-19 cases at the facility.
    21 Jul 2021
    Found that the required change of ownership notice was not received by the licensing agency from the new owners, while residents had received only a change of management notice.
    21 Jul 2021
    Identified deficiencies related to ownership change notification not being received by the licensing agency during the inspection.
    • § 87405
    • § 1569.50
    • § 87211
    19 Jul 2021
    Identified deficiencies including missing first-aid certificates for eight of nine staff, one staff member lacking TB/health screening, and incomplete medication administration records for three residents; one resident was missing two prescribed medications. The first-aid kit was up to date, and an exit interview with appeal rights was provided.
    19 Jul 2021
    Identified deficiencies in employee files, medication records, and missing prescribed medications during an inspection visit.
    • § 1569.191(a)(1)
    15 Jul 2021
    Found missing Covid-19 postings at the entrance and throughout the site, and two staff not associated with the site; two residents were receiving hospice care. Noted cracked and peeling flooring in common areas, while the kitchen, lighting, temperature, alarms, and food supplies were in acceptable condition, and deficiencies were cited.
    15 Jul 2021
    Identified deficiencies in Covid-19 postings, flooring maintenance, and staff records during annual inspection.
    13 Jul 2021
    Identified missing medication for R1, oxygen being used in multiple rooms without identification or posted signs, and water temperatures in rooms 42 and 43 at 138.5 degrees. Deficiencies were noted and cited, and administrative documents including designation of administrative responsibility, personnel report, and administrator's certificate were requested by close of business on 7/16/2021.
    • §
    • § 87465
    • §
    13 Jul 2021
    Observed deficiencies in medication administration, lack of proper oxygen identification, and water temperature outside acceptable range during inspection.
    • § 87411
    • § 87465(a)(5)
    • § 87411
    • § 87465(6)
    28 Jun 2021
    Determined the allegation that a resident was locked in the courtyard could not be supported by evidence. Courtyard doors were unlocked and could lead into the building, and staff and a witness could not confirm when or if the incident occurred.
    28 Jun 2021
    Determined that the allegation of charging above the SSI rate for admissions occurred, after reviewing two admission agreements and related guidelines. Found that the agreements did not provide a clear breakdown of services and fees or an agreed-upon extra monthly amount beyond the SSI rate.
    • § 87507(g)(3)
    28 Jun 2021
    Confirmed charging above SSI rate for admissions. Admission agreement did not align with ALWP guidelines.
    • § 87303(a)(1)
    • § 87355(e)(2)
    • § 1569.50(3)
    21 Jun 2021
    Investigated a complaint and identified that a resident did not receive medical care in a timely manner. Evidence from documents and interviews supported that finding.
    21 Jun 2021
    Identified a February–March 2021 staffing shortage that affected medication distribution, with staff working double shifts. Found the allegation that residents were not receiving medications as prescribed unfounded, and the allegation that a resident fell and did not receive adequate medical care unfounded.
    21 Jun 2021
    Confirmed allegation that Resident did not receive timely medical care. Deficiencies cited may lead to penalties if not corrected.
    16 Jun 2021
    Found cockroaches in a resident’s apartment, with three residents reporting cockroaches in their units, and pest control visits and treatments were conducted. Observed mold in a resident’s freezer with ice packs not frozen, and a resident was sent to the hospital after reporting leg pain.
    • § 87303(a)
    • § 87307(d)(2)
    16 Jun 2021
    Observed dead cockroaches in residents' apartments and common areas during the visit. Mold found in refrigerator with warm bottles of liquid.
    • § 87468.2(a)(1)
    • § 87411(a)(d)
    28 May 2021
    Investigated Allegation #1 regarding staff not ensuring the resident was adequately fed; determined no preponderance of evidence. Investigated Allegation #2 regarding failure to administer the prescribed Ensure supplement; evidence supported the allegation.
    28 May 2021
    Confirmed insufficient documentation that supplements were given to a resident as ordered, but unsubstantiated allegations of inadequate feeding practices.
    • § 87405(h)(4)
    18 Mar 2021
    Investigated the allegation that a resident did not receive medications as prescribed. Found MAR documentation and staff interviews indicated medications were administered, and there was insufficient evidence to prove the allegation.
    18 Mar 2021
    Reviewed allegation of resident not receiving medication as prescribed, but evidence was inconclusive, so the claim remains unsubstantiated.
    • § 87465(a)(5)
    21 Aug 2020
    Found PPE stocked and safety signage posted, with clean spaces throughout and a well‑stocked kitchen. Temperatures in resident rooms were mostly comfortable after a past chiller issue; snacks were provided by medical staff, and no deficiencies identified.
    21 Aug 2020
    Confirmed presence of adequate Personal Protective Equipment and food supplies, cleanliness throughout the facility, and comfortable temperatures for residents.
    19 Feb 2020
    Investigated a missing narcotic medication incident where oxycodone and norco disappeared while in the facility's custody, leading to a Sheriff's Department investigation and staff suspensions.
    • § 87217
    06 Jan 2020
    Reviewed incident involving a resident being transported back from a skilled nursing facility without re-appraisal, leading to hospitalization for various medical issues.
    26 Dec 2019
    Investigated allegations of document falsification and improper room heating; determined false as documents were genuine and heating system worked properly. Room temperature noted at 90°F on 11/3/19, with resident leaving the next day.
    20 Dec 2019
    Completed inspection found all areas of the facility to be in compliance with regulations and standards.
    06 Dec 2019
    Visited care home to clarify discrepancy in fire clearance capacity; no citations issued.
    18 Oct 2019
    Inspection identified no deficiencies and observed clean, well-maintained living areas, proper food storage, and necessary safety measures in place.

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