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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002886
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:09:53 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, 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
01/09/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230109150714
FACILITY NAME:CITRUS CREST CARE HOME 1FACILITY NUMBER:
345002886
ADMINISTRATOR:CHAVEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:6906 HENNING DRIVETELEPHONE:
(916) 728-1338
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 2DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Admininstrator- Muamoudou Aidara Soumahoro TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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- Staff lock the refrigerator/freezer.
INVESTIGATION FINDINGS:
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On 05/16/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 01/09/2023. LPA met with administrator, Muamoudou Aidara Soumahoro, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, residents’ (R1 and R2) physician’s report, admission agreement, and medical records.

Continue on page LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 6
Control Number 25-AS-20230109150714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CITRUS CREST CARE HOME 1
FACILITY NUMBER: 345002886
VISIT DATE: 05/16/2023
NARRATIVE
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Allegation: Staff lock refrigerator/freezer. – Substantiated.

On 01/12/2023, LPA Keosavang arrived at the facility unannounced to open complaint investigation. LPA Keosavang toured the facility and observed the refrigerator locked and inaccessible to residents in care. LPA gathered interview statement from S1. Interview statement from S1 indicated, the facility has always had the refrigerator locked. If residents are hungry and would like some food resident can let staff know and they will prepare the food for residents. The facility does not have residents with eating disorders or on a special diet. Staff were advised that they could not lock the refrigerator, it was unlocked immediately. S1 indicated resident did not go without food or snacks. S1 indicated residents are provided meals and snacks throughout the day. Facility records confirmed with facility records on file that the facility does not have a waiver granted the facility to implement such actions.

Due to this information CCL 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.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20230109150714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CITRUS CREST CARE HOME 1
FACILITY NUMBER: 345002886
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily
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Administrator removed lock from refrigerator door and agrees to make that permanent unless a waiver is granted by CCL to keep the refrigerator locked. On 5/16/2023, refrigerator remained unlocked.
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living functions such as eating, sleeping, or elimination.This requirement is not met as evidenced by: Based on observation, refrigerator was locked and inaccessible to residents in care which poses a potential health, safety, or personal rights risk to person 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/09/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230109150714

FACILITY NAME:CITRUS CREST CARE HOME 1FACILITY NUMBER:
345002886
ADMINISTRATOR:CHAVEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:6906 HENNING DRIVETELEPHONE:
(916) 728-1338
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 2DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Admininstrator- Muamoudou Aidara Soumahoro TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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- Staff are not serving food of quantity or quality to meet the needs of residents.
- Residents are told to stay in their rooms until staff awake.
- Residents are told to go to bed early.
- Residents can not leave their room after 6 PM.
- Resident missed meals.
INVESTIGATION FINDINGS:
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On 05/16/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final findings Community Care Licensing received on 01/09/2023. LPA met with administrator, Muamoudou Aidara Soumahorond, explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, residents’ (R1 and R2) physician’s report, admission agreement, and medical records.

Continue on page LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20230109150714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CITRUS CREST CARE HOME 1
FACILITY NUMBER: 345002886
VISIT DATE: 05/16/2023
NARRATIVE
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Allegation: Staff are not serving food of quantity or quality to meet the needs of residents. – Unsubstantiated.

On 1/12/2023, LPA Keosavang toured the interior and exterior of the facility. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. The Department conducted interviews with residents in care. Interview statement received from R3 indicated, R3 has no concerns regarding the food that is being provided at the facility. R3 stated, R3 will request for food and it will be delivered to R3. R3 often requests for snacks and ice cream. Interview statement received from R4 indicated, there is enough food at the facility.

Allegation: Residents are told to stay in their rooms until staff awake. – Unsubstantiated.

The Department requested for R1 and R2’s contact information to gather interview statements. R1 and R2’s contact information provided was not in service. The Department was unable to locate R1 and R2 to gather interview statement.

The Department received interview statements from a total of two (2) residents. R3 and R4 denies that staff tells residents to stay in their rooms until staff awakes.

Allegation: Residents are told to go to bed early. – Unsubstantiated.

The Department requested for R1 and R2’s contact information to gather interview statements. R1 and R2’s contact information provided was not in service. The Department was unable to locate R1 and R2 to gather interview statement. Interview statement received from R3 indicated, resident often stays in the common area to watch TV. R3 stated staff does not force residents to go to bed early. Interview statement received from R4 indicated, residents are not told to go to bed early. R4 stated R4 usually goes to be around 11 PM.

Allegation: Resident can not leave their room after 6 PM. – Unsubstantiated.

The Department requested for R1 and R2’s contact information to gather interview statements. R1 and R2’s contact information provided was not in service. The Department was unable to locate R1 and R2 to gather interview statement. Interview statement received from R3 indicated the alleged allegation is not true and resident can leave their rooms after 6 PM. Interview statement received from R4 indicated, R4 is able to leave the room whenever R4 likes to.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20230109150714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CITRUS CREST CARE HOME 1
FACILITY NUMBER: 345002886
VISIT DATE: 05/16/2023
NARRATIVE
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Allegation: Resident missed meals. – Unsubstantiated.

The Department requested for R1 and R2’s contact information to gather interview statements. R1 and R2’s contact information provided was not in service. The Department was unable to locate R1 and R2 to gather interview statement. Interview statement received from R3 indicated, R3 has no concerns regarding the food that is being provided at the facility. R3 stated, R3 will request for food and it will be delivered to R3. R3 often requests for snacks and ice cream. Interview statement received from R4 indicated, R4 has never missed a meal at the facility.

Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6