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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700077
Report Date: 08/31/2021
Date Signed: 08/31/2021 06:06:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
342700077
ADMINISTRATOR:NICOLS, MARTINFACILITY TYPE:
740
ADDRESS:6825 SUNRISE BLVDTELEPHONE:
(916) 721-0644
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 19DATE:
08/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rouzbeh Moradhasel, Executive DirectorTIME COMPLETED:
06:20 PM
NARRATIVE
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While at the facility for a separate matter, Licensing Program Analyst (LPA) Praveen Singh conducted this inspection to follow-up on a serious incident report submitted to Community Care Licensing on 8/5/21. LPA met with Executive Director Rouzbeh Moradhasel and discussed the purpose of the inspection.

It was reported that on 8/4/21, R1 received another resident's medication during medication pass. During today's inspection, LPA received additional information pertaining to this incident. On 8/4/21, S1 who was the nurse on duty, became distracted and pulled meds from the wrong cart and gave four medications prescribed to a different resident to R1. S2 immediately became aware of mistake and informed R1's doctor and family and updated R1's ISP (individualized service plan). R1 was monitored and reported to have no adverse reactions to the med error. The medications that were wrongfully administered were: Eliquis 2.5mg, Losartan Potassium 100 mg, Metoprolol 50 mg, Coq 10 100mg

Deficiencies cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809-D. If the deficiency is not corrected by the noted due date civil penalties may be assessed.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 236-4743
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2021
Section Cited

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(c) (2) Once ordered by the physician the medication is given according to the physician's directions.
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This requirement is not met as evidenced by:

On 8/4/21, R1 received four medications from another resident's centrally stored medications.
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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: Laura MunozTELEPHONE: (916) 236-4743
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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