345002924-4-27-2023-59-AS-KHOS-CRGK7E-20230503073900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002924
Report Date: 04/27/2023
Date Signed: 04/27/2023 03:56:09 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, 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
04/24/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230424101750

FACILITY NAME:	CITRUS PINES SENIOR LIVING		FACILITY NUMBER:	345002924
ADMINISTRATOR:	KELLY, JANELYN		FACILITY TYPE:	740
ADDRESS:	8300 PATTON AVE		TELEPHONE:	(279) 529-2045
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 4	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Janelyn Kelly, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee spoke inappropriately in the presence of residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint or conduct a 10-day inspection. LPA met with Janelyn Kelly, Administrator, and Jhamil Espino, Licensee, and explained purpose of inspection.

During today's inspection, LPA discussed the incident relating to the allegation with (2) residents (R1 and R2) and Administrator and (1) of the members of the Licensee, Jhamil. LPA also reviewed charting notes from R1's file and the incident report (LIC624) submitted to the Department on 4/23/23, following the incident. Additionally, LPA discussed the incident with the Ombudsman who was at the facility recently to also investigate. The results of the investigation are as follows:

Based on interviews and documentation, it was determined that a second member of the Licensee (S1) who was present in the facility on 4/23/23 (from 12:30 pm- 2:00 pm approximately), was arguing aggressively with (2) guests he brought over, causing R1 to feel mentally stressed and uncomfortable to leave her room to use the restroom.
**cont on 9099C(1)...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230424101750

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 PINES SENIOR LIVING	FACILITY NUMBER: 345002924
	VISIT DATE: 04/27/2023

NARRATIVE

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9099C(1).. R1's room is near the outside patio where the arguing was taking place. Charting notes entered in R1's file. from 4/23/23- 4/25/23, document R1's concern of feeling uncomfortable for her safety.

Interview with the Administrator and Jhamil Espino, revealed that there have been several discussions with S1, since January 2023, related to the business operations. Department notes show that on 3/1/23, S1 had arrived at the facility and was speaking to the Administrator and staff in a loud, aggressive tone.

R1 stated to LPA on 4/27/23 that the facility is a very nice place and is happy here but felt "very uncomfortable" with the S1 and his guests on 4/23/23 due to the anger and aggression observed from the conversation. R2 who was also interviewed on 4/27/23 stated that he heard the "tail end" of the meeting with S1 and the guests, and he knows resident R1 was "very stressed" from it. R2 stated he doesn't believe residents, R3 and R4, heard the conversation.

Espino stated to LPA on 4/27/23 that he has asked S1, several times, not to discuss business operations when on the facility premises. LPA observed an email that was sent from Espino to S1 on 3/1/23 following a prior incident at the facility where S1 was asked not to discuss any business matters at the facility.

Based on information obtained, 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, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator.

A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230424101750

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 PINES SENIOR LIVING	FACILITY NUMBER: 345002924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/11/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to consult with a legal representative and provide written follow up the Department based on what legal advice is given to the facility. Administrator agrees to continue to request that any discussion regarding the business be conducted outside of the facilty premises.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the residents had a safe, healthful and comfortable environment on 4/23/23 and on 3/1/23, which posed a potential health and safety risk and personal rights violation to clients in care.	8 9 10 11 12 13 14	Administrator to provide the Department with requested documentation by fax/email by 5/11/23.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

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