I toured and recently placed my father-in-law here - the facility is clean, welcoming, and the staff are genuinely caring and attentive. Meals are appealing, activities are engaging (Tina Evans gets special praise), memory care is professional, and the spacious studios with kitchenettes make this an affordable, comfortable fit. I get regular updates and feel my family member is well supported; overall I'm very pleased and would recommend.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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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
Reviews
3.72·(71)
Overall rating
5
4
3
2
1
Care
3.5
Staff
3.9
Meals
3.7
Amenities
2.8
Value
3.8
Pros
Affordable pricing and perceived value
Tasty, well-presented meals and social dining atmosphere
On-site licensed nurse coverage
24/7 staff presence
Friendly and welcoming front-desk and caregiving staff
Engaging activities program with strong activity leadership
Spacious studio apartments with kitchenettes
Regular family updates and event support
Clean, maintained common areas
Convenient central location near medical services and shopping
Quick placement and admission flexibility
Memory-care expertise and dementia-focused training
Positive resident socialization and successful transitions
Cons
Inconsistent clinical oversight and chronic-condition management
Variable medication-administration reliability
Slow response to call-button and resident requests
Inconsistent staffing levels and caregiver availability
Variable staff professionalism and communication tone
Breakdowns in family communication and care coordination
Unreliable housekeeping and laundry processes
Odor concerns and uneven sanitation in some areas
Aging facility infrastructure and deferred updates
Accessibility and safety design limitations
Limited secure outdoor access for memory-care residents
Unclear level-of-care disclosures and upgrade pricing
Billing and refund process problems
Bare-bones activity programming in some units
Summary of reviews
Legacy Oaks of Sacramento elicits a strongly mixed set of impressions. Many families and visitors praise the community for affordability, a central location close to medical services and shopping, and a warm, friendly staff. Positive comments focus on well-presented meals, social dining, a visible on-site nursing presence, and an activities program led by engaged leadership that can produce clear social and emotional benefits for residents. Several reviewers described smooth transitions, timely placement when needed, and helpful front-desk and activities staff who provide regular family updates and event support.
At the same time, a substantive portion of feedback highlights operational inconsistencies that affect quality of care. Concerns cluster around clinical oversight (including wound care and chronic-condition management), medication-administration reliability, and slow responses to call buttons and resident requests. These clinical and responsiveness issues are frequently tied to variable staffing levels and coverage; when staffing is stretched, reviewers describe delays in assistance, late or missing medications, and unattended medication carts. Families also noted occasional lapses in communication and follow-through from management and the front office, including confusion over levels of care, upgrade pricing, and challenges obtaining refunds or billing clarifications.
The facility itself is characterized as older but serviceable. Reviewers note both clean, well-maintained common areas and persistent sanitation or odor concerns in some parts of the building. Some units have been updated (carpet to wood, refreshed rooms), while others retain dated finishes and accessibility limitations (door designs, parking/back access, sliding exits). Memory-care provisions receive mixed comments: staff knowledge of dementia and some supervised outdoor time are positives, but secure outdoor access can be limited and wandering risk remains a management issue. Activity offerings vary by unit; when the program is active residents appear engaged, but other accounts describe bare-bones calendars and limited stimulation.
Management appears to be in transition in places, with reports of a new director and ownership changes producing noticeable improvements for some families while others continue to experience communication and organizational gaps. Staffing culture also presents a split picture: many reviewers praise attentive, compassionate caregivers and a helpful activities director, while others report inconsistent professionalism and conduct that affects family trust.
For prospective residents and families: the community offers strong value, social dining, and on-site clinical presence that can meet many needs, particularly for residents who prioritize affordability and social engagement. Because reviews reflect variability in clinical responsiveness, staffing, and housekeeping consistency, visitors should observe care routines, ask targeted questions about staffing levels at different times of day, medication policies and medication-cart safeguards, wound- and chronic-condition protocols, laundry turnaround, and detailed pricing/upgrade disclosures. Speak with current families when possible and request to see recent care plans or incident-response procedures to judge how the facility matches the specific clinical and safety needs of your loved one.
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Location
Legacy Oaks of Sacramento is located at 1922 Morse Ave, Sacramento, CA, 95825.
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...
Legacy Oaks of Sacramento offers competitive pricing, with rates starting at a cost of $2,800 per month.
Legacy Oaks of Sacramento offers assisted living and memory care.
There are 30 photos of Legacy Oaks of Sacramento on Mirador.
The full address for this community is 1922 Morse Ave, Sacramento, CA 95825.
No, Legacy Oaks of Sacramento does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In California, the Department of Social Services' Community Care Licensing Division licenses residential care facilities for the elderly, conducting inspections and investigating complaints.
License number
342702896
Status
Licensed
Facility type
Residential Care Elderly
Capacity
160 residents
Licensee
MORSE INVESTMENT PARTNERS LLC;CSG SR LVNG MGMT LLC
Investigated two complaints and found no deficiencies.
22 May 2026Inspection
22 May 2026Inspection
Observed that temperatures in living/ dining areas were not consistently maintained at a comfortable level for residents.
Type A87303(b)
22 May 2026Complaint
22 May 2026Complaint
Investigated a complaint about call-light response times and found that staff did not consistently answer call lights timely, creating safety and resident rights concerns.
Type BCCR 87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)
21 May 2026Complaint
21 May 2026Complaint
Investigated a complaint alleging failure to follow a resident care plan. Found a substantiated deficiency related to medication management and care planning.
Type ACCR Title 22 87465(a)(1)Incidental Medical and Dental Care
21 May 2026Complaint
21 May 2026Complaint
Investigated the complaint and found no deficiencies. The allegations were unsubstantiated.
15 May 2026Inspection
15 May 2026Inspection
Identified failures to perform 2-hour checks, update care plans after medical changes and incidents, and maintain medications, creating safety risks for residents.
Type A87464(f)(1)
Type A87463(g)
Type A87465(a)
Type A87101(c)(3)
Type A1569.2(c)
13 May 2026Inspection
13 May 2026Inspection
Observed insufficient staff coverage during meal periods, preventing timely attention to residents' requests for additional drinks and meal substitutions. In addition, maintenance and safety issues were found, including a nonworking faucet, a drawer off its hinge, and smoking occurring in a courtyard not designated for that activity.
Type A87468.2(a)(4)
Type A87468.1(a)
Type B87303(a)
13 May 2026Complaint
13 May 2026Complaint
Found noncompliance with shower assistance policies by staff, with evidence of lapses in following procedures.
HSC 1569.2(c)1-7(c)Care and supervision
12 May 2026Complaint
12 May 2026Complaint
Investigated a complaint and found that medications were not consistently provided as prescribed, residents were moved without proper notice, and finances showed insufficient controls.
CCR 87465(a)(4)Incidental Medical and Dental Care
CCR 87405(d)(3)Administrator - Qualifications and Duties
CCR 87205(b)Accountability of Licensee Governing Body
CCR 87213Finances
CCR 87468.2(a)(16)Additional Personal Rights of Residents in Privately Operated Facilities (a)(16)
30 Apr 2026Complaint
30 Apr 2026Complaint
Found no deficiencies cited after investigating multiple complaints.
30 Apr 2026Inspection
30 Apr 2026Inspection
Identified a resident incident involving severe back pain and hospital transport; no deficiencies cited.
29 Apr 2026Complaint
29 Apr 2026Complaint
Investigated the allegation that a resident was refused admission after hospital discharge and found the allegation unfounded; no deficiencies were observed or cited.
13 Apr 2026Complaint
13 Apr 2026Complaint
Investigated allegations of lacking resident activities and transportation; identified lack of a full-time activities coordinator since February 13, 2026, and transportation inconsistencies, with a new driver hired on April 13, 2026.
Type BCCR 87219(f)Planned Activities
Type BCCR 87464(f)(6)Basic Services (f) – Transportation
03 Apr 2026Complaint
03 Apr 2026Complaint
Investigated the medication destruction procedures and found inconsistencies with documentation and witness signatures, including narcotics not witnessed for destruction.
CCR Title 22, 87465(i)Incidental Medical and Dental Care
27 Mar 2026Inspection
27 Mar 2026Inspection
Identified an interim administrator during an unannounced visit. Observed staff assisting residents; no deficiencies were cited.
24 Mar 2026Inspection
24 Mar 2026Inspection
Investigated an incident involving two residents; no deficiencies were cited.
20 Mar 2026Inspection
20 Mar 2026Inspection
Identified violations related to administrator qualifications and duties, licensee accountability, and financial records.
Type A87405
Type A87205
Type B87213
17 Mar 2026Complaint
17 Mar 2026Complaint
Investigated allegations that one resident sexually assaulted another and that a fight occurred with no manager present; reviewed records and interviewed residents, and there was not enough evidence to prove the allegations.
02 Mar 2026Inspection
02 Mar 2026Inspection
Found no deficiencies.
27 Feb 2026Inspection
27 Feb 2026Inspection
Investigated a complaint, identified two deficiencies, and assessed civil penalties for repeated violations within one year.
Type B87466
Type B87211(c)
25 Feb 2026Complaint
25 Feb 2026Complaint
Investigated a complaint and found that significant incidents were not reported promptly and communications with residents' representatives were not consistently addressed during a period of short staffing.
Type A87466
Type A87211(c)
09 Feb 2026Complaint
09 Feb 2026Complaint
Investigated allegations about coercing hospice use, threats, theft of belongings, night supervision failures, care plan noncompliance, rough handling, and medication management. Found multiple deficiencies related to residents' rights, supervision, and care processes.
Type ACCR 87468.2(a)(7)Personal Rights - Participation in care planning
Type ACCR 87468.2(a)(8)Personal Rights - Freedom from neglect and abuse
Type ACCR 87411(a)Personnel Requirements - General
Type ACCR 87468.2(a)(25)Personal Rights - Protection of property from theft or loss
Type ACCR 1569.626(a)Training - Dementia care
Type ACCR 87465(a)(4)Plan for incidental medical and dental care; self-administered meds
14 Jan 2026Inspection
14 Jan 2026Inspection
Identified a 24-hour reporting violation for suspected physical abuse of an elder. Found inadequate dementia care training for staff.
Type B87211(c)
Type B87412(c)(1)(B)
18 Dec 2025Inspection
18 Dec 2025Inspection
Observed two staff files lacked required annual training and updated certifications; noted a cold hallway with a door propped open and hot water temperatures outside allowed range; no deficiencies were cited during this visit.
09 Dec 2025Complaint
09 Dec 2025Complaint
Identified disrepair in the memory care area, including lifted flooring, missing ceiling tiles, and roof wear. Investigated whether staffing shortages affected residents' needs; interviews yielded mixed responses and did not establish that staffing caused unmet needs.
Type B87303(a)(a)
23 Oct 2025Inspection
23 Oct 2025Inspection
Identified several immediate risks to residents, including an unlocked laundry room with toxic chemicals, a medication room left unlocked with cart keys exposed, a rear exit door delay not functioning, and confidential records left exposed.
Type A87309(a)
Type A87465(h)(2)
Type A15699(a)
Type B87468.2(a)(2)
03 Oct 2025Complaint
03 Oct 2025Complaint
Investigated two allegations: cooling systems not operable and potential incorrect medication administration. Observed heat in common areas and some bedrooms, with portable cooling used; interviews and records reviewed regarding medications.
Type B87303(a)
02 Oct 2025Complaint
02 Oct 2025Complaint
Identified that a resident was not checked every two hours during the night shift and reviewed the circumstances of the resident's death.
Type A87466
25 Sept 2025Inspection
25 Sept 2025Inspection
Identified delays in responding to residents' call lights, with several responses taking longer than an hour.
Type B87411(a)
25 Sept 2025Complaint
25 Sept 2025Complaint
Investigated allegation that staff removed a resident's pendant during care... found insufficient evidence to prove the allegation, and noted delays in responding to a call bell.
23 Sept 2025Complaint
23 Sept 2025Complaint
Investigated the allegation that water was not clean and drinkable and found it unfounded.
23 Sept 2025Complaint
23 Sept 2025Complaint
Investigated an allegation that smokers and smoke blocked public access; observed smoke at a substantial distance from the entry and at least 50 feet from windows, and advised enforcing house rules; there was insufficient evidence to prove the violation.
16 Sept 2025Complaint
16 Sept 2025Complaint
Investigated a complaint about call buttons not always being operational and found the call alert system was not functioning properly. Interim measures were being implemented while the system was addressed.
Type BCCR 87303(i)(1)Maintenance and Operation
15 Sept 2025Complaint
15 Sept 2025Complaint
Observed that staff did not consistently wash hands after caring for residents or removing gloves, and gloves were reused or discarded improperly.
Type B87470(a)(1)(B)(5)
13 Aug 2025Complaint
13 Aug 2025Complaint
Investigated a complaint about medication management and found a lapse in administering a bedtime medication when a resident returned late, creating an immediate risk.
CCR 87465(a)A plan for incidental medical and dental care shall be developed by each facility.
06 Aug 2025Complaint
06 Aug 2025Complaint
Observed room 37 malodorous and unsanitary with a broken toilet, standing water, stained carpet, and other disrepair, with maintenance preparing for repairs. Also noted an open medication room door with keys left in the cart, an unalarmed rear exit, an unlocked laundry room with cleaning supplies accessible to residents, and unsecured resident files.
Type A87303(a)
11 Jul 2025Complaint
11 Jul 2025Complaint
Investigated whether staff ensured residents had clean bedding. Found bedding in inspected rooms was clean, and interviews indicated bedding was changed weekly or with showers.
04 Jun 2025Complaint
04 Jun 2025Complaint
Investigated a wallet theft allegation and a claim of disrespect by staff. Interviews and records did not establish evidence to support these claims.
03 Jun 2025Complaint
03 Jun 2025Complaint
Observed that a resident missed 16 doses of five medications over four days and staff did not assist with scheduled showers.
Type A87465(a)(2)
Type B87468.2(a)(1)
27 May 2025Inspection
27 May 2025Inspection
Investigated an incident in which a resident was slapped on 05/22/25. Licensing conducted a case management review and found no deficiencies cited.
14 May 2025Inspection
14 May 2025Inspection
Identified an order excluding a staff member and noted the staff roster was updated accordingly. No deficiencies were observed.
14 May 2025Complaint
14 May 2025Complaint
Investigated the allegation that staff did not afford resident privacy and concluded there was insufficient evidence.
11 Dec 2024Inspection
11 Dec 2024Inspection
Identified compliance during a prelicensing visit, with adequate food supplies, proper medication handling, and resident activities; no deficiencies were observed.
15 Nov 2024Complaint
15 Nov 2024Complaint
Investigated concerns that residents' dietary needs were not met, housekeeping was not performed, and showers were not provided timely.
Type B87555(b)(7)
Type B87555(b)(17)
Type B87464(f)(4)
Type B87307(d)
29 Oct 2024Inspection
29 Oct 2024Inspection
Identified medication errors and documentation gaps that affected residents, including OTC vitamins not ordered, unreported pharmacy changes, and outdated medication lists.
Type A87465(a)(4)
29 Oct 2024Complaint
29 Oct 2024Complaint
Investigated an allegation that staff refused to allow a resident to return. The resident was returned on 10/25/24 after hospital treatment.
11 Oct 2024Complaint
11 Oct 2024Complaint
Investigated an allegation of a questionable death and a resident not receiving timely medical care; found delays in responding to a pendant alarm and gaps in medical monitoring and documentation.
Type A87465(g)(g)
26 Sept 2024Complaint
26 Sept 2024Complaint
Identified failures in supervising residents, safeguarding personal possessions, assisting with dental care, and timely reporting of medication issues.
Type B87465(a)(1)(1)
Type B87465(a)(2)(1)
Type B87217(b)(b)
26 Sept 2024Complaint
26 Sept 2024Complaint
Investigated the allegation that staff did not follow a physician's order.
25 Sept 2024Complaint
25 Sept 2024Complaint
Investigated allegations that a resident's room was not cleaned and sanitized in a timely manner, that residents were not provided a healthy and safe environment, and that staff did not provide reasonable accommodations for roommate choice.
Type B87307(d)(2)
Type B87303(a)
24 Sept 2024Complaint
24 Sept 2024Complaint
Identified that a staff member cleaned a resident in a rough manner.
Type B87468.2(a)(4)
05 Sept 2024Inspection
05 Sept 2024Inspection
Observed that no deficiencies were cited during this visit.
15 Aug 2024Complaint
15 Aug 2024Complaint
Identified failure to provide 30 days' notice before eviction; eviction letter was dated 03/15/2024 but mailed on 03/20/2024.
Type A87224
08 Aug 2024Inspection
08 Aug 2024Inspection
Investigated a resident who brought a dog into the community without prior approval and without an agreement with the roommate.
25 Jul 2024Complaint
25 Jul 2024Complaint
Investigated the allegation that a resident sustained multiple falls due to insufficient supervision, and concerns about delayed medical care and hydration; evidence showed repeated falls and hospitalizations and questions about fall-prevention measures and supervision.
Type A1569.312(e)
Type B1569.49(f)
25 Jul 2024Inspection
25 Jul 2024Inspection
Identified that a resident required one-to-one care and that fall prevention protocols were not in place, creating immediate health and safety risks.
23 Jul 2024Complaint
23 Jul 2024Complaint
Investigated a claim that a resident's clothes were removed from the room without consent and found no conclusive evidence identifying who took the clothing.
Type B1569.152
Type B1569.153
Type B1569.153(d)
Type B1569.154
17 Jul 2024Complaint
17 Jul 2024Complaint
Investigated a complaint alleging staff did not ensure a resident received showers and that a resident was left in soiled diapers; both allegations were unsubstantiated.
08 Jul 2024Complaint
08 Jul 2024Complaint
Investigated allegation that lack of supervision allowed elopement; evidence indicated residents were supervised and no elopement occurred.
05 Jul 2024Complaint
05 Jul 2024Complaint
Identified that staff did not meet residents' toileting needs and did not ensure residents were adequately fed, and noted concerns about management attention.
Type A87464(f)(4)
03 Jul 2024Complaint
03 Jul 2024Complaint
Investigated a complaint about resident privacy, dignity, and a mandated reporting requirement. Found the reporting failure was supported, while the privacy and dignity concerns were not supported.
Type B87211(a)(1)
13 Jun 2024Complaint
13 Jun 2024Complaint
Identified that the allegation that resident rooms were not clean; observations showed resident rooms clean and in good repair.
14 May 2024Complaint
14 May 2024Complaint
Investigated the allegation that staff did not ensure a resident received a phone correspondence. Findings were unsubstantiated and no deficiencies were observed.
13 May 2024Inspection
13 May 2024Inspection
Identified an incident where a caregiver used a resident's debit card for a personal purchase after agreeing to run an errand.
03 May 2024Complaint
03 May 2024Complaint
Identified issues included lack of a centrally stored medication log, inadequate showers for several residents, and meals not meeting residents' needs. Other concerns about activities and linens were investigated.
Type A87465(a)(6)(a)
Type B87464(f)(4)
Type B87555(b)(5)
01 May 2024Inspection
01 May 2024Inspection
Identified a deficiency where the administrator did not provide the conservator with specific examples to justify an eviction notice.
Type A87405(d)
23 Apr 2024Inspection
23 Apr 2024Inspection
Identified that a pre-admission appraisal was not conducted for a resident, creating an immediate risk to health and safety.
Type A87468.2(a)
23 Apr 2024Inspection
23 Apr 2024Inspection
Identified an illegal eviction due to mismatches between the eviction notice sent to the resident and the version reviewed, and missing supporting documents; a deficiency was cited.
16 Apr 2024Complaint
16 Apr 2024Complaint
Observed that a resident discharged from the hospital was not allowed to return to care, and a three-day eviction notice was not provided.
Type A87724(b)
03 Apr 2024Complaint
03 Apr 2024Complaint
Investigated a complaint that the phone system was inoperable and found issues with a single incoming line and voicemail; five staff admitted to sleeping during overnight shifts.
Type A1569.312(a)
03 Apr 2024Complaint
03 Apr 2024Complaint
Investigated an unlawful eviction; the eviction letter sent to the resident's POA differed from the version reviewed by licensing and did not include the attached exhibits.
27 Mar 2024Inspection
27 Mar 2024Inspection
Identified a resident-on-resident altercation in the dining area; staff intervened, the aggressor was transported for hospital evaluation, and police were notified, with no deficiencies cited.
20 Mar 2024Complaint
20 Mar 2024Complaint
Investigated a complaint alleging staff did not allow a resident to obtain medical assistance. The investigation found that the resident requested transportation to the hospital for a rash, but transportation was not provided.
Type A87465(a)(1)
18 Mar 2024Complaint
18 Mar 2024Complaint
Found that the allegation that staff did not allow a resident's family member visitation was unfounded.
29 Feb 2024Inspection
29 Feb 2024Inspection
Identified a lack of a full-time activities director and a sharp decrease in planned activities across care areas.
Type B87217(f)
Type B87219(f)
27 Feb 2024Inspection
27 Feb 2024Inspection
Found that two residents with a history of aggression were moved without proper assessments and placed together, and that incident reporting and reappraisals were not consistently completed.
Type A87405(h)(5)
22 Feb 2024Complaint
22 Feb 2024Complaint
Investigated an allegation that visitation was refused; reviewed records and interviews to understand the circumstances.
22 Feb 2024Inspection
22 Feb 2024Inspection
Observed no deficiencies during an unannounced case management visit after a resident altercation; staff were interviewed and records reviewed.
21 Feb 2024Complaint
21 Feb 2024Complaint
Identified that staff did not provide adequate supervision to residents. The concern involved a resident's call alert with no staff response.
Type A87411(a)
21 Feb 2024Inspection
21 Feb 2024Inspection
Observed staffing changes and updated administrative information, including new hires and a planned interview for an activities director, as well as new service contracts. No deficiencies were observed during the visit.
16 Feb 2024Complaint
16 Feb 2024Complaint
Investigated allegations that staff did not meet residents' toileting needs and did not adequately feed a resident; also reviewed claims that residents were left unsupervised and that the call system was in disrepair, with no evidence of ongoing problems found.
Type A87101(c)(3)
Type A87464(f)(4)
Type A1569.2(c)
Type B87464(f)(1)
16 Feb 2024Complaint
16 Feb 2024Complaint
Investigated allegations that staff did not meet residents' hygiene needs and did not provide adequate food service.
Type B1569.312(a)
Type B87464(f)(4)
15 Feb 2024Complaint
15 Feb 2024Complaint
Identified that a resident was left in soiled clothing for an extended period; two hospice residents were not showered or their clothes changed in a timely manner.
Type A87625(b)(3)
15 Feb 2024Inspection
15 Feb 2024Inspection
Identified that two residents with histories of aggression were paired as roommates, resulting in an injury to one resident. Found gaps in reassessment of condition changes, incident documentation, and supervision related to their safety.
Type A87462
Type A87705(b)(2)
06 Feb 2024Inspection
06 Feb 2024Inspection
Identified missing health screenings for staff and related noncompliance led to a civil penalty for failure to correct.
Type A87411(f)
02 Feb 2024Complaint
02 Feb 2024Complaint
Found that staff did not answer the main telephone line, so calls were often redirected to voicemail and not answered promptly.
Type B87468.1(a)(14)
01 Feb 2024Complaint
01 Feb 2024Complaint
Investigated a complaint about staff not timely responding to resident alerts; found the alert system malfunctioned and staff responses were delayed.
Type A87303(i)(1)(B)
24 Jan 2024Inspection
24 Jan 2024Inspection
Found missing health screenings for several staff within their first week and a resident with dementia did not receive an annual reassessment.
Type B87411(f)
Type B87705(c)(5)
17 Jan 2024Complaint
17 Jan 2024Complaint
Investigated a complaint about cigarette smoke in the building. Back doors were observed propped open on two occasions, allowing smoke to enter, and residents reported smelling smoke.
Type A87468.1(a)(2)
11 Jan 2024Complaint
11 Jan 2024Complaint
Found that an incident involving bruises on a resident went unreported to licensing, that a resident showed changing behavior and did not receive a medical evaluation, and that supervision lapses allowed dangerous items to be accessible.
Type A87211(a)(1)
Type A87465(a)(1)
Type A87705(f)(1)
11 Jan 2024Inspection
11 Jan 2024Inspection
Observed a strong odor in the memory care area indicating incontinence-related cleanliness issues. The non-memory care area did not have the odor.
10 Jan 2024Complaint
10 Jan 2024Complaint
Investigated cleanliness and privacy allegations. Found a dirty room (room #33) with a malodorous memory care area; privacy practices appeared to protect residents during interactions.
Type A87303(a)
10 Jan 2024Complaint
10 Jan 2024Complaint
Identified that residents did not receive medications as needed due to medication not available, and noted staff training gaps along with cleanliness concerns.
Type A87465(a)(4)
Type A1569.625(b)
Type B87303(a)
10 Jan 2024Inspection
10 Jan 2024Inspection
Identified that three medication technicians had not completed the required training before assisting residents with self-administration of medications.
Type A1569.69(a)(1)
10 Jan 2024Complaint
10 Jan 2024Complaint
Investigated an allegation that staff did not keep residents' rooms clean. Observed a dirty room with a malodorous environment and a room with moldy food and dirty shower conditions, while housekeeping staff were on duty and a regular cleaning schedule existed.
Type A87303(a)
21 Dec 2023Complaint
21 Dec 2023Complaint
Identified multiple safety and record-keeping deficiencies at a licensed care setting, including missing grab bars in bathrooms, improper medication administration and disposal, loss of resident belongings, delayed response to call alerts, and incomplete incident reporting.
Type A87303(e)(4)
Type A87468.2(a)(1)
Type A87465(a)(4)
Type A87465(i)(1-4)
Type A87218(a)
Type A87411(d)(3)
Type B87211(a)(1)
12 Dec 2023Complaint
12 Dec 2023Complaint
Investigated an allegation that staff did not provide a resident's records to the resident's authorized representative in a timely manner. The inquiry included interviews, a walkthrough, and review of billing practices.
06 Dec 2023Complaint
06 Dec 2023Complaint
Identified pest sightings reported by residents; some roaches were observed, but there was no evidence of an ongoing infestation.
05 Dec 2023Complaint
05 Dec 2023Complaint
Identified a violation of residents' personal rights after staff recorded residents, made inappropriate comments, and posted clips on social media.
Type B87468.2(a)(8)
21 Nov 2023Complaint
21 Nov 2023Complaint
Found odor issues in some resident rooms, delays in PRN medications and pendant-call responses, and concerns about residents' dignity and respect; other earlier issues were investigated but not supported.
Type A87307(d)(2)
Type B87468.1(a)(2)
Type B87465(b)
Type B87303(i)(1)(B)
15 Nov 2023Inspection
15 Nov 2023Inspection
Observed laminate flooring peeling away from concrete in room 16, creating a tripping hazard and safety risk for residents. A deficiency was cited for not keeping the area in good repair.
Type B87303(a)
09 Nov 2023Inspection
09 Nov 2023Inspection
Identified ongoing non-compliance and a high deficiency history, with a conference to discuss staffing, medication management, resident rights, and governance.
09 Nov 2023Inspection
09 Nov 2023Inspection
Observed an unannounced case management visit to serve an Immediate Exclusion letter and related documents to a resident; attempts to contact the resident included a voicemail and certified mail, access was gained through a building resident, and an exit interview was conducted.
08 Nov 2023Inspection
08 Nov 2023Inspection
Identified that reappraisals were not completed for a resident after a change in condition, creating potential health and safety risks.
Type A87467
08 Nov 2023Inspection
08 Nov 2023Inspection
Conducted a case management visit; an Immediate Exclusion letter was served, and an exit interview was conducted.
03 Nov 2023Inspection
03 Nov 2023Inspection
Identified that video footage of memory care residents was posted to social media by a staff member, prompting police involvement and a case management follow-up; no deficiencies were cited.
24 Oct 2023Inspection
24 Oct 2023Inspection
Identified that 4 of 52 employees listed were not associated to the site in Guardian, violating criminal record clearance requirements.
Type A87355(e)(2)
Type A87355(c)
06 Oct 2023Complaint
06 Oct 2023Complaint
Investigated concerns about kitchen staffing and overall staffing levels and found a lack of a qualified kitchen staff person and insufficient staff to meet residents' needs.
Type B87555(a)(17)
Type B80072(a)(2)
20 Sept 2023Complaint
20 Sept 2023Complaint
Investigated an allegation that staff did not administer residents' medications as prescribed; MAR records were incomplete and several residents reported medications were not being administered.
Type B87465(a)(1)
06 Sept 2023Complaint
06 Sept 2023Complaint
Identified that a resident's needs were not met.
Type B87465(a)(1)
07 Jul 2023Complaint
07 Jul 2023Complaint
Investigated two allegations: air conditioning not working properly and cigarette smoke smell. Observations and interviews indicated no deficiencies cited.
23 Jun 2023Complaint
23 Jun 2023Complaint
Investigated allegations about staff mishandling medications and documenting administration; found incomplete medication administration records.
Type A87465(d)(3)
23 Jun 2023Inspection
23 Jun 2023Inspection
Identified that there was not a current qualified administrator in place because the administrator's certificate had expired and recertification was not postmarked until after the expiry.
20 Jun 2023Inspection
20 Jun 2023Inspection
Observed residents who were unable to leave unassisted unsupervised outside on the sidewalk near the building. This raised health and safety concerns due to insufficient supervision.
Type B87468.2(a)(4)
20 Jun 2023Inspection
20 Jun 2023Inspection
Identified a small fire in the laundry room that was extinguished; residents evacuated safely and no deficiencies were cited.
08 Jun 2023Inspection
08 Jun 2023Inspection
Found two deficiencies cited under state licensing regulations were cleared.
Type A87405(f)
Type B87555(b)(26)
31 May 2023Complaint
31 May 2023Complaint
Investigated the allegation that the admission agreement was not followed regarding a rate increase. Found that the allegation could not be corroborated.
16 May 2023Inspection
16 May 2023Inspection
Found no current certified administrator and insufficient stock of nonperishable for a week and perishable for two days.
Type B87405(f)
Type B87555(b)(26)
09 May 2023Complaint
09 May 2023Complaint
Identified a broken walk-in freezer and storage of frozen foods in a vacant refrigerator, resulting in disposal of pork loins and diced ham cubes.
Type A87303(a)
12 Jan 2023Inspection
12 Jan 2023Inspection
Observed a clean, safe environment with functional fire safety equipment, adequate food supplies, and health screening procedures.
03 Jan 2023Complaint
03 Jan 2023Complaint
Identified issues with staff responsiveness to residents' calls for assistance and with ensuring residents receive medications as prescribed.
Type A87464(f)(4)
Type B87468.1(a)(2)
29 Dec 2022Complaint
29 Dec 2022Complaint
Investigated concerns about feeding, bathing, and linens. Found that meals were delivered to a resident in their room, the resident refused multiple showers, bed linens were not changed due to refusals, and staff were present but there were staffing shortages.
13 Dec 2022Complaint
13 Dec 2022Complaint
Investigated an allegation of insufficient staffing and safety concerns about wheelchair access to a smoking area, along with related access and communication issues. The findings indicated the allegations were not supported.
06 Dec 2022Complaint
06 Dec 2022Complaint
Investigated allegations that staff did not assist with meal services, did not adequately manage medications, did not ensure medications followed physicians' instructions, did not keep the resident's room clean, and did not provide clean laundry; found there was not a preponderance of evidence to support the claims.
07 Nov 2022Complaint
07 Nov 2022Complaint
Identified that a resident's catheter bag was not emptied in a timely manner; other allegations about bathroom needs, medication administration, staff threats, and room cleanliness were not supported by evidence.
Type ACCR87623(b)(2)(A)
01 Sept 2022Complaint
01 Sept 2022Complaint
Identified that a resident's linens were soiled and cockroaches were found in a room.
Type B87307(d)(2)
12 May 2022Complaint
12 May 2022Complaint
Found a cockroach infestation in one room and unsanitary conditions; other abuse and care-related allegations were not supported by evidence.
Type B87307(d)(2)
11 May 2022Complaint
11 May 2022Complaint
Found that a resident sustained multiple fractures. Staff did not inform the conservator of changes in condition and medical care was not provided promptly.
Type A87464(f)(1)(c)
Type A87211(a)(2)
Type A87465(j)
26 Apr 2022Complaint
26 Apr 2022Complaint
Identified concerns about incontinence care, oxygen monitoring, self-administered medication, and changes in condition, and noted a cleanliness issue and a medication handling deficiency.
Type B87303(a)
14 Mar 2022Complaint
14 Mar 2022Complaint
Investigated a complaint alleging staff did not follow the resident's care plan, and personal hygiene needs were unmet, along with understaffing and insufficient food and water. Findings did not establish the allegations.
14 Feb 2022Complaint
14 Feb 2022Complaint
Found that only Med-Techs dispense medications on a set schedule, residents reported no issues with medications, and there was no evidence of verbal abuse toward residents.
14 Feb 2022Inspection
14 Feb 2022Inspection
Observed proper infection control measures, stocked PPE, and complete staff and visitor logs, with updated policies; no deficiencies cited.
08 Feb 2022Complaint
08 Feb 2022Complaint
Investigated the allegation that a staff member mishandled a resident's medication. The investigation found centrally stored medications were not kept in a safe, locked place and were accessible to unauthorized individuals.
Type A87465(h)(2)
03 Feb 2022Inspection
03 Feb 2022Inspection
Observed a clean, well-maintained environment with functional safety systems and infection control measures in place; no deficiencies were cited.
03 Feb 2022Inspection
03 Feb 2022Inspection
Found the site clean, well-maintained, and compliant with safety and health requirements.
06 Jan 2022Inspection
06 Jan 2022Inspection
Participated in a COMP II interview and demonstrated understanding of the applicable California Title 22 regulations during the pre-licensing readiness process.
19 Nov 2021Inspection
19 Nov 2021Inspection
Observed proper PPE use, posted signs for hand washing and social distancing, and visitor policies with masking and testing rules. Staff maintained logs, a stocked PPE supply room, and monthly training occurred, and no deficiencies were cited.
04 Nov 2021Complaint
04 Nov 2021Complaint
Identified Neglect/Lack of Supervision involving delays in medication administration and feeding assistance due to staffing shortages. Found that a hygiene-related allegation lacked sufficient evidence.
Type A87411(a)
Type A87608
01 Nov 2021Complaint
01 Nov 2021Complaint
Identified that medications were not always administered as prescribed and dietary plans were not consistently followed, with documentation gaps noted.
Type B87465(a)(5)
Type B87458(b)(4)
Type B87464(f)(3)
29 Oct 2021Complaint
29 Oct 2021Complaint
Identified missing medication with no dose records for a resident, and failure to report incidents; also found staff sleeping in designated resident rooms.
Type A87465(h)(2)
Type A87211(a)(2)
28 Oct 2021Complaint
28 Oct 2021Complaint
Identified cockroaches at the location; other concerns lacked sufficient evidence.
27 Oct 2021Complaint
27 Oct 2021Complaint
Investigated the allegation of a foul odor in the building; residents denied noticing any odor and staff reported pest treatment, with no deficiencies cited.
27 Oct 2021Complaint
27 Oct 2021Complaint
Investigated the allegation that staff did not provide timely assistance to residents. The final notes indicated there was not sufficient evidence to support the allegation.
26 Oct 2021Inspection
26 Oct 2021Inspection
Observed an unassessed, unstaged pressure injury with no medical assessment or care arranged.
Type B7465(a)(1)
25 Oct 2021Inspection
25 Oct 2021Inspection
Observed multiple maintenance and sanitation deficiencies, including a locked resident bathroom, ceiling leaks, overflowing trash, no soap in one area, and a broken washer. These conditions created potential safety and sanitation concerns for residents.
Type B87303(a)
20 Oct 2021Complaint
20 Oct 2021Complaint
Identified the allegation that the admission agreement claimed a signal system was in every resident bedroom, while memory care pull cords were deactivated and not functioning.
Type A87303(i)(1)(A-C)
Type B87507(f)
06 Oct 2021Inspection
06 Oct 2021Inspection
Identified health and safety concerns, including dead cockroaches and other pests, a leaking bathroom sink, a broken fountain, and overgrown vegetation creating an exit hazard. Also noted staff occupying resident rooms, raising concerns about proper operation and safety.
Type B87303
Type B87208(a)(7)(b)
01 Oct 2021Complaint
01 Oct 2021Complaint
Investigated the allegation that medications for a resident were mismanaged. The findings did not establish that the allegation occurred.
07 Sept 2021Complaint
07 Sept 2021Complaint
Investigated complaints about residents being locked out of rooms, delays in medication administration, and staff behavior, along with concerns about COVID-19 precautions. Found documentation and access control issues and confirmed problems with COVID-19 safety measures.
23 Aug 2021Complaint
23 Aug 2021Complaint
Investigated a complaint about delayed staff response to call buttons and a broken air conditioning system; found delays occurred and the AC issue was being addressed, and that residents had access to water.
Type B87464(f)(4)
23 Aug 2021Inspection
23 Aug 2021Inspection
Identified that a resident left without staff assistance and was found hours later in a park, raising safety concerns about supervision.
Type A1569.2(c)
11 Aug 2021Inspection
11 Aug 2021Inspection
Found no deficiencies cited during a virtual case management visit.
28 Jul 2021Inspection
28 Jul 2021Inspection
Identified ongoing Covid-19 compliance issues, change of ownership notice reporting problems, and licensee abandonment concerns.
26 Jul 2021Complaint
26 Jul 2021Complaint
Investigated the allegations that staff failed to seek timely medical care for a resident and that oxygen supply ran out during a power outage; found the allegations unfounded.
23 Jul 2021Inspection
23 Jul 2021Inspection
Identified failure to report COVID-19 positive cases promptly and noncompliance with COVID-19 mitigation and administrator requirements.
Type A1569.50(3)
Type B87211(2)
Type B87405(d)(2)
21 Jul 2021Inspection
21 Jul 2021Inspection
Identified that the required 30-day notice of change of ownership was not provided to residents or to the licensing department.
Type B1569.191(a)(1)
19 Jul 2021Inspection
19 Jul 2021Inspection
Identified deficiencies in staff health records and medication management, including missing first aid certificates, incomplete health screenings, and gaps in resident medication records.
Type A87465(a)(5)
Type A87465(6)
Type B87411(c)(1)
Type B87411(f)
15 Jul 2021Inspection
15 Jul 2021Inspection
Identified cracked and peeling common flooring, two staff not associated to the facility, and missing COVID-19 postings and pre-screening practices.
Type A87355(e)(2)
Type A1569.50(3)
Type B87303(a)(1)
13 Jul 2021Inspection
13 Jul 2021Inspection
Observed hot water temperature out of range, a resident's medication was missing, and warning signs for oxygen in use were not posted.
Type A87465(a)(1)
Type A87465(a)(5)
Type B87465(a)(3)
28 Jun 2021Complaint
28 Jun 2021Complaint
Identified that the admissions agreement did not provide a comprehensive breakdown of services and fees, including amounts beyond the SSI rate for residents under the assisted living waiver program.
Type B87507(g)(3)(A)(1)
Type B87507(g)(3)(A)(2)
Type B87507(g)(3)(A)(3)
28 Jun 2021Complaint
28 Jun 2021Complaint
Investigated the allegation that a resident was locked out of the site. Found insufficient evidence to determine whether the incident occurred, and no deficiencies were issued.
21 Jun 2021Complaint
21 Jun 2021Complaint
Investigated the allegation of inadequate staffing for medication distribution during February and March 2021.
Type B87405(h)(4)
21 Jun 2021Complaint
21 Jun 2021Complaint
Investigated the allegation that a resident did not receive medical care in a timely manner. The review included medical records, interviews with staff, and observations.
Type A87468.2(a)(1)(4)
Type B87411(a)(d)
16 Jun 2021Complaint
16 Jun 2021Complaint
Investigated a complaint about a cockroach infestation and a refrigerator that wasn't working properly. Found cockroaches in multiple residents' apartments, including dead cockroaches in one unit, and that pest control had been performed with a treatment during the visit.
Type B87307(d)(2)
Type B87303(a)
28 May 2021Complaint
28 May 2021Complaint
Investigated two allegations: one claimed residents were not adequately fed; another claimed staff did not follow a resident's doctor's orders. A deficiency was cited for the medication-related issue.
Type B87465(a)(5)
18 Mar 2021Complaint
18 Mar 2021Complaint
Investigated the allegation that a resident did not receive prescribed medications; interviews and MAR reviews did not establish the allegation.
21 Aug 2020Inspection
21 Aug 2020Inspection
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.
19 Feb 2020Inspection
19 Feb 2020Inspection
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.
Type A87217
06 Jan 2020Inspection
06 Jan 2020Inspection
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 2019Complaint
26 Dec 2019Complaint
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 2019Inspection
20 Dec 2019Inspection
Completed inspection found all areas of the facility to be in compliance with regulations and standards.
06 Dec 2019Inspection
06 Dec 2019Inspection
Visited care home to clarify discrepancy in fire clearance capacity; no citations issued.
18 Oct 2019Inspection
18 Oct 2019Inspection
Inspection identified no deficiencies and observed clean, well-maintained living areas, proper food storage, and necessary safety measures in place.
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Mirador Living is not affiliated with the owner or operator(s) of Legacy Oaks of Sacramento. The information above has not been verified or approved by the owner or operator. For exact information, please contact Legacy Oaks of Sacramento directly. There is no cost for this service. We are compensated by the community you select.
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