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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700077
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:44:57 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20210211090417
FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:DAVIS, KAYLAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 21DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Oliver Aden, Administrator TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
Licensee did not supervise resident
Staff spoke to resident inappropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with administrator Oliver Aden upon LPA’s arrival. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “Resident sustained unexplained injuries while in care”. LPA interviewed staff and conducted a file review. LPA interviewed relevant party in which they stated R5 was observed to have bruising on their body for unknown reasons. LPA interviewed 7 staff members in which they stated R5 wanders within the facility and at times gets in altercations with other residents. Staff state other residents get upset with R5 due to their wandering in their room and residents have grabbed R5. Staff stated they have observed bruising on resident before.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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-20210211090417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 07/22/2021
NARRATIVE
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Staff interviews indicate R5 is also a fall risk. LPA reviewed R5’s needs and service plan which indicates R5 wanders into other resident rooms and requires redirecting. LPA reviewed R5’s charting notes and observed on 11/27/20, 12/18/20, 12/23/20 and 3/2/21 that R5 had bruising for unknown reasons. In addition on 1/29/21 and 2/25/21 R5 was observed to have a mark present after a fall. LPA found that resident did sustain unexplained injuries while in care, however LPA was unable to determine if the injuries were due to facilities lack of supervision or neglect. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated allegation, “licensee did not supervise resident”. LPA interviewed relevant party in which they stated R5 is not supervised and wanders into other resident room. LPA interviewed 7 staff members in which they stated R5 is ambulatory and resident does wander frequently throughout the day. PM staff stated R5 normally remains in the common areas, and at times resident does begin to wander into other resident rooms but they can easily redirect them. Am staff stated R5 does wander throughout the day and they are consistently redirecting resident and encouraging them to participate in activities. LPA reviewed residents needs and service plan in which it states resident wanders into other resident rooms, and when observed to redirect to activities, or offer food and water. LPA reviewed resident physician report in which it states resident has a diagnosis of dementia and has wandering, aggressive, and confused behaviors. Due to the information gathered LPA finds resident does having wandering behaviors however LPA was unable to determine if R5 is not properly supervised. LPA finds allegation to be UNSUBSTANTIATED.
LPA investigated allegation, “Staff spoke to resident inappropriately”. LPA interviewed relevant party in which they stated staff speak inappropriately to R4. LPA interviewed 7 staff in which they stated they have not observed other staff talk inappropriately to R4 or other residents. LPA interviewed 1 resident in which they stated the staff are nice to them. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20210211090417

FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:DAVIS, KAYLAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 21DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Oliver Aden, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility not keeping medication destruction records
Prescription medications not destroyed upon termination of services
Licensee did not update residents' reappraisals
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with administrator Oliver Aden upon LPA’s arrival. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, Facility not keeping medication destruction records”. LPA interviewed relevant party in which they stated resident narcotic medications are not being counted and recorded properly and over the counter medications are not being recorded on the centrally stored medication record. On 4/26/21 LPA inspected the medication room including the centrally stored medication records, destruction records, and the narcotic count book.
Continuation on 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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-20210211090417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 07/22/2021
NARRATIVE
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LPA investigated allegation, “Licensee did not update resident’s reappraisals”. LPA interviewed staff and conducted a record review. LPA interviewed relevant party in which they stated R4's behaviors and changes was not updated in the reappraisals. LPA interviewed Resident Care Coordinator and they stated a reappraisal is completed annually and upon change of condition. LPA reviewed R4’s needs and service plan dated 9/30/2020 which indicates the care needed and the behaviors R4 displays. In addition, LPA reviewed R4’s needs and service plan dated 3/20/21 which indicates residents care needs, behaviors, and shows resident is now on hospice care. LPA reviewed R4’s charting notes which documents residents behaviors and facilities communication with R4’s physician and hospice team. LPA reviewed R4’s physician report dated on 4/30/20 and resident is now on hospice services. Due to the information gathered, LPA finds allegation UNFOUNDED.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 27-AS-20210211090417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
VISIT DATE: 07/22/2021
NARRATIVE
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LPA observed 4 residents records and observed medications were properly documented on the centrally stored medication record, destruction log, narcotic log, and the MAR. LPA interviewed the resident care coordinator and the facility nurse in which they stated they are not aware of a time when the narcotic book and destruction record went missing. Resident care coordinator stated all medications including over the counter medications are recorded on the centrally stored medication record. Facility nurse stated upon a resident moving out or passing away facility use the destruction record and two staff must destroy the medications together and sign off on the sheet. Due to the information gathered, LPA finds allegation to be UNFOUNDED.

LPA investigated allegation, “Prescription medications not destroyed upon termination of services”. LPA interviewed relevant party in which they stated facility is storing a surplus of narcotic medications at the facility. On 4/26/21 LPA inspected the medication room including the centrally stored medication records, destruction records, and the narcotic count book. LPA did not observe a surplus of medications that needed to be destroyed. Administrator stated if a resident moves out of the facility staff count the medication and then release them to the resident’s responsible party. If a resident passes away administrator stated two staff members will destroy medications, and sign off on the sheet. Destroyed medication are placed in a container and a company picks of the container quarterly or as needed. LPA interviewed resident care coordinator and facility nurse in which they stated when a resident passes away on hospice, a hospice nurse and the facility nurse destroy the medications together and sign off on the sheet. LPA reviewed 4 residents destruction records and observed them to filled out correctly with 2 signatures. Due to the information gathered LPA finds allegation to be UNFOUNDED.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20210211090417

FACILITY NAME:COURTE AT CITRUS HEIGHTS, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:DAVIS, KAYLAFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 21DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Oliver Aden, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Medications not administered as prescribed by physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with administrator Oliver Aden upon LPA’s arrival. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
LPA investigated allegation, “medications not administered as prescribed by physician”. LPA reviewed two resident medications, comparing with resident MAR and physician orders. LPA reviewed R6 MAR and observed resident was prescribed ivermectin 3mg to be taken on 4/10/21 and then another dose 14 days later. LPA observed resident missed the dose that was prescribed to be given 14 days later. In addition R6’s MAR shows resident did not get her cream that was prescribed on 4/10/21. LPA reviewed R7's medications and observed resident is missing their PRN NYQUIL medication from their supply of medications. Due to the information gathered LPA finds allegation to be SUBSTANTIATED.
Deficiencies at are cited on 9099-D. Appeal Rights provided. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20210211090417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COURTE AT CITRUS HEIGHTS, THE
FACILITY NUMBER: 342700077
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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Administrator agrees to conduct a training with all staff that handle medication. Training to include documentation and reviewing physician orders. Training date to be sent into LPA by 7/23/20.
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This requirement is not met as evidenced by: Based on observation and record review the licensee did not provide medication prescribed by physician which poses 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.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7