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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700077
Report Date: 12/21/2020
Date Signed: 12/21/2020 05:58:26 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2020 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 27-AS-20200709100010
FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:BAUTISTA-COLMENARES, DONNAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 38DATE:
12/21/2020
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kayla Davis, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Residents sustained multiple falls while in care
Staff neglect resulted in a resident's death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Huusfeldt met with Kayla Davis. Today's visit was conducted over the phone due to COVID precautions.
The department investigated allegations of “Residents sustained multiple falls while in care”. The department reviewed resident records, and conducted interviews with staff and relevant parties. Review of facility records indicated that between 6/1/2020 to 7/9/2020, there were 17 resident falls. Staff interviews indicated that they were understaffed during this time due to staff quitting or calling off. Review of staff schedules show that during some of the shifts when residents had falls, there were only two caregivers on shift. In addition, LPA reviewed the facility file and the following is written in the plan of operation, “The licensee shall ensure that there are an adequate number of caregivers to support each residents physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20200709100010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 12/21/2020
NARRATIVE
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The Courte at Citrus Heights will provide care for its residents based on a 1 caregiver to 7 residents." Due to the information gathered LPA finds allegation to be SUBSTANTIATED.

The department investigated allegations of “Staff neglect resulted in a resident's death”. The department reviewed resident records, hospital records, emergency services records, and conducted interviews with staff and relevant parties. On June 30, 2020 R1 was found outside in the courtyard which is located in the middle of the facility. Interviews indicated it is unknown how long R1 was outside before they were found. R1's assigned caregiver and another staff member last saw R1 at approximately 1500 hours. R1 was left at the activity, and assigned caregiver reported they should have been notified when R1 left the activity, but they were not notified. Upon discover of R1 in the courtyard, emergency services were called.
Records from emergency services indicate a call was received at 1649 hours and paramedics arrived at 1703 hours. Records from emergency services indicted R1 was in the sun, with their head in the shade. Records indicate that R1’s skin was hot and dry, and their skin was sunburned. Records indicate the outdoor temperature was over 90 degrees Fahrenheit and R1’s temperature was 104.1 degrees Fahrenheit. R1 was taken to the hospital and CPR was initiated on route. Hospital medical records indicate R1’s final diagnosis as cardiac arrest and second- degree burns.
Staff interviewed and facility records obtained, indicate that R1 had a fall history. R1's activities of daily living task sheet , dated 1/25/2020, noted that R1 had a potential for falls due to poor judgement related to dementia. Chart notes indicated that R1 had an un-witnessed fall in the courtyard on 6/28/2020. Chart notes dates 6/19/2020 indicate concern that R1 was starting to ambulate independently. It is noted the Executive Director at the time, Donna Bautista-Colmenares, was notified and it is documented that the ED said R1 is allowed to walk around if R1 wanted to. R1 was on hospice care from 4/11/20 to 6/9/2020.
Staff interviewed reported that R1 was always walking around the facility and R1 would walk very fast/run when they were agitated. Records obtained indicated R1's Resident Service Plan was completed on 8/11/2019, and was due for an assessment on 2/27/2020.
Continuation on 9099-C.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200709100010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 12/21/2020
NARRATIVE
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Under ambulatory services needs, it is noted R1 ambulates independently ; however R1 tends to walk faster when they are anxious. Staff should escort R1 when their gait is unsteady.

Due to the information gathered LPA finds allegation to be SUBSTANTIATED.Administrator was informed that a civil penalty assessment based on Health and Safety Code § 1548 is currently under review and may be assessed on a later date, as a result of R1's death while in care at the facility. Once civil penalty assessment has been determined, LPA will return on a future date to assess the civil penalty.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in R1’s death. Failure to correct the deficiency may result in further civil penalties. Appeal rights were provided. Exit interview conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-C, LIC 9099-D, LIC 811, LIC 421M and appeal rights were received. Administrator is to print out the LIC 9099, LIC 9099-C, LIC 9099-D, LIC 421M and return signed copies of the reports.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20200709100010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2020
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Administrator to send LPA a copy of staff schedule for the next three months to verify staffing is sufficient. Staff schedule to be provided to LPA at the beginning of each month.
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This requirement is not met as evidenced by: Based on interviews and record reviews, facility did not have sufficient staffing to meet the needs of the residents which poses an immediate health & safety risk to residents in care.
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Type A
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Section Cited
CCR
87705(c)
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87705(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Facility shall develop a plan to ensure all residents with dementia are receiving the care as needed by the resident. In-service training is required for all staff. Proof of training to be sent to CCLD by POC date.
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This requirement is not met as evidenced by: Based on interviews and records reviews, facility did not have adequate number of direct care staff to support residents needs which poses an immediate health & safety risk to residents in care.
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A civil penalty of $500 was issued.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2020 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 27-AS-20200709100010

FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:BAUTISTA-COLMENARES, DONNAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 38DATE:
12/21/2020
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kayla Davis, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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 Staff failed to address outbreak at the facility
Staff are not taking universal precautions for residents while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Huusfeldt met with Kayla Davis. Today's visit was conducted over the phone due to COVID precautions.
The department investigated allegations of “Staff failed to address outbreak at the facility”. On 7/11/20 Administrator at the time informed LPA and Department of Public Health that a staff member (S1) tested positive for Covid-19. S1 was tested on 7/8/20 and facility received test results on the 11th. On 7/23/20 LPA and a nurse from Department of Public Health conducted a tele-visit over facetime. It was observed facility had required posters posted throughout the facility, and observed facilities supply of PPE. The nurse did not have concerns over the facilities operation. LPA conducted daily calls with administrator from 7/14/20 to 8/18/20. Due to the information gathered LPA finds allegation to be UNFOUNDED.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20200709100010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 12/21/2020
NARRATIVE
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The department investigated allegations of “Staff are not taking universal precautions for residents while in care”. LPA reviewed facilities Infection Control Policy and COVID-19 plan. Both plans address universal precautions for staff and residents. On 7/13/20 LPA toured the facility and observed all staff wearing proper PPE and the facility appeared to be clean and sanitary. A televisit was conducted with LPA, administrator at the time and department of public of health nurse on 7/23/20 over facetime. Administrator toured the facility in which all staff were wearing PPE properly. In addition, administrator showed LPA and the nurse their supply of PPE and it appeared to be sufficient. LPA observed housekeeper schedules and observed there are two full time housekeepers on the schedule. Interviews with relevant party indicate there is not sufficient PPE for staff to use and there was a time there was not a housekeeper to keep the facility clean. Due to the information gathered LPA finds allegations to unfounded.

A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview and copy of reports emailed to Administrator.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2020 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 27-AS-20200709100010

FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:BAUTISTA-COLMENARES, DONNAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 38DATE:
12/21/2020
UNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kayla Davis, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff failed to keep the facility free from pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Huusfeldt spoke to administrator Kayla Davis over the phone to deliver complaint findings due to Covid precautions.

The department investigated allegations of “Staff failed to keep the facility free from pests”. LPA toured the facility on 7/13/20 and did not observe any pests. LPA observed receipts from a pest inspection for the month of May 2020 through August 2020. The receipts did indicate there were pests, however the facility was getting routine services for pests. Interview with relevant party indicate there were bugs inside the facility. Although there were bugs present inside the facility, the facility was actively trying to eradicate the issue therefore allegation was found to be UNSUBSTANTIATED.

Exit interview conducted and copy of reports emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7