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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700077
Report Date: 11/04/2025
Date Signed: 11/04/2025 03:47:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250909160232
FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:AMY BOLLIERFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 38DATE:
11/04/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Brenda Cobos, AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff are not meeting the needs of residents who require two person assists in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the investigation and deliver findings to a complaint the Department received on September 9, 2025. LPA met with Brenda Cobos, Administrator, aned stated the reason for the inspection. LPA observed other managers and facility staff present as well as residents in the activities room or resting in their rooms.

During the course of the investigation, LPA interviewed (6) facility staff, (3) managers and (1) family member who visits the facility regularly. LPA also observed the dining room during lunch on (2) occasions, September 12, 2025 and November 4, 2025, and reviewed documentation includin staffing schedules and care plans for residents requiring a (2) person assist.

The results of the investigation are as follows:

cont on 9099C-1..
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 59-AS-20250909160232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 11/04/2025
NARRATIVE
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9099C-1. Allegation: Staff are not meeting the needs of residents who require two person assists in a timely manner. The allegation states the facility does not have adequate staff for residents needing two person assists and residents are waiting longer than needed.

LPA conducted (3) staff interviews on September 12, 2025 and an additional (3) on November 4, 2025. All staff who were interviewed indicated that caregiver staffing levels have been significantly cut since on/around September 1, 2025. Previously, there were (7) care staff scheduled on the "am" and "pm" and staffing levels were initially decreased to (4), with (1) floater, then went to (4) care staff.

One staff stated in September, 2025 that if (1) staff calls off, then there are (3) staff for a period of time, and the facility will contact "on-call staff", explaining that some staff had their hours "cut" and haven't worked for a week, and others are working double shifts. This staff stated she has "two residents" that need a two -person assist for "all of their care" and a third resident that needs one due to "behavioral reasons", and asserted that (1) caregiver is "doing all of the care except for transfers", which can take 5-20 minutes. Additionally, "there are a lot of residents on full assist and it takes 20-45 minutes for a lot of the residents".

Staff interviews conducted in September 2025, confirmed that management will assist during lunches and with supervising 10+ residents while one caregiver is assisting with showers; however, managers do not generally assist with ADL's, and with less staff, there isn't time to provide incontinent checks 4x/shift, and it's taking longer to attend to residents. Residents are also at an increased risk of falling with less staff to assist. LPA observed weekly staffing schedules from September through November, 2025, to reflect (4) care staff scheduled on the "am" and "pm" shifts and (2) care staff on the NOC shift. The Department previously confirmed that (7) care staff were scheduled on the "am" and "pm" shifts prior to September 1, 2025.

Management stated that the staffing change was a result of being overstaffed during the facility's (3) year probationary period with the Department and that they will assist care staff and Med-Tech staff when needed. LPA observed managers to be seating residents, serving water, and feeding residents in the dining room during lunch on September 12, 2025 and on November 4, 2025.Staff interviews conducted on November 4,2025, revealed that the facility has "cut staff hours significantly and residents are having to wait longer for all care", commenting "at least 10 minutes". Additionally, staff confirmed that showers are being delayed and while many residents are under hospice care and hospice staff will come out and provide a shower, a facility staff must assist the hospice staff during each shower. The administrator stated on November 4, 2025 the facility recently began discussions with management and corporate nurses regarding asking hospice staff to provide (2) of their own staff for showers. *cont on 9099C-2..
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250909160232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 11/04/2025
NARRATIVE
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9099C-2... One staff provided the example that if one resident takes 30-40 minutes in the morning to receive a shower, it can delay another (9) residents from receiving care, when there is a 1:10 ratio. Staff interviews revealed that "managers are not helping from 6-8:00 am with showers" , showers are being given late, and stated 5-6 staff are needed on each shift. A second staff stated residents are not getting their teeth brushed daily due to not enough time as a result of less staffing.

Multiple staff interviews indicated that last Saturday, November 1, 2025, (2) staff called out for the "am" shift and the RCC filled in and was calling staff; however, only (2) staff were present for the first (45) minutes and then (3) staff from 6:45 am- 10:00 am until a fourth care staff was added.

A Med-Tech staff stated "for sure they cut caregiver hours as they said they were overstaffed" and that staff are now rushing to provide care due to less staffing. Interviews revealed that caregivers and (1) Med-Tech quit due to the job being too stressful after positions were cut, and "for the most part, management steps in". Lastly, multiple staff stated that staff generally "don't have time for breaks".

On September 12, 2025, LPA was provided with care plans for (6) of (38) residents needing a two person assist. Review of staffing schedules show (4) care staff were scheduled to work on the "am" and "pm" shifts and (2) care staff on the NOC shift. A family member of a resident who is a two- person assist stated "residents may have to wait, but it's not an unreasonable amount of time- up to 15 minutes at the most", adding that on weekends and holidays, the facility is "sometimes short staffed" and last Saturday, November 1, there were fewer staff here.

Based on information obtained during the investigation, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 9099-D page.

Exit interview. Copy of report and appeal rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250909160232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) 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. This requirement is not met as evidenced by:
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Licensee/Administrator will discuss adding a 5th staff to "am" and "pm" shift; incentive program started 11/3/25 for picking up a shift; discussions with hospice bringing additional staff for showers; possible float added during "am" and "pm"
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that there was adequate staffing levels to provide timely assistance with care needs, on Saturday, November 1, 2025 (6:00 am- 8:00 am approximately) as there were (2) staff scheduled to work the "am" shift but called out, which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4