345920230-5-19-2026-59-AS-LCRR-DUHNAA-20260528101713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920230
Report Date: 05/19/2026
Date Signed: 05/19/2026 01:53:12 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
04/21/2026 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20260421151442

FACILITY NAME:	CITRUS HEIGHTS SENIOR LIVING		FACILITY NUMBER:	345920230
ADMINISTRATOR:	SAHOTA, SUKHMAN		FACILITY TYPE:	740
ADDRESS:	8440 EDGECLIFF COURT		TELEPHONE:	(916) 716-5999
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	05/19/2026
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Sukh Sahota, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff are locking resident in their room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on April 21, 2026. LPA met with Sukh Sahota, Administrator, and stated the reason for the inspection. LPA observed (2) residents present in the common area and (2) residents resting in their rooms and was advised (1) resident was attending a day program. LPA observed (2) visitors arrive for a resident and staff, Jackie Cole-Cochrane preparing lunch.

During the investigation, LPA interviewed the Administrator, an acquaintance of staff (S1), a family member of resident (R1) and resident (R2). LPA was unable to interview resident (R1) and staff (S1 and S2), who last worked at the facility through on/around March 31, 2026. LPA reviewed documentation including (R1's) Pre-Appraisal, Physician's Report and other notes. The results of the investigation are as follows:

*cont on 9099C-1..

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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 5

Control Number 59-AS-20260421151442

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: CITRUS HEIGHTS SENIOR LIVING	FACILITY NUMBER: 345920230
	VISIT DATE: 05/19/2026

NARRATIVE

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9099C-1.. Resident (R1) moved to the facility on March 17, 2025 with a primary diagnosis of Alzheimer's Dementia. The Physician's Report notes that (R1) could be confused/disoriented, exhibits wandering/sundowning behaviors and is an "elopement risk". Additionally the report notes (R1) is ambulatory, not able to leave the facility unassisted, and requires assistance with bathing and medications.

Allegation: Staff are locking resident in their room. The allegation states there is a resident (R1) who is locked in their room after hours to prevent them from leaving the facility since throughout the day the resident would attempt to elope.

The Administrator stated prior staff (S2) placed a lock on (R1's) door for approximately a week and he was not aware of this as (S2) did not tell him. The administrator explained it was (S2's) job to check on (R1) at night", stating "(S2) would sleep through" (R1) getting up, exiting through the front door, and not get up when the "alarm went off" and "(S1) would have to go after (R1)". After (S1) left the facility, (S2) put a lock on (R1's) bedroom door at night". The administrator stated he removed the knob to turn the lock and disabled the locking mechanism, over a year ago, when he found out about this as (S2) quit.

Resident (R1) was asked if there was ever a lock on their bedroom door and was not able to articulate well and provide an answer, but appeared pleasantly confused. (R1's) family member stated she was not aware of a lock ever being on (R1's) door and (R1) did not say anything to her about it.

LPA observed the door knob on (R1's) door, and all other resident doors, to not have a locking mechanism in place when inspected on April 21, 2026 or on May 19, 2026.

Based on information obtained, the allegation is found 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) citation is issued on the 9099-D page.

Exit interview. Copy of report provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20260421151442

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: CITRUS HEIGHTS SENIOR LIVING	FACILITY NUMBER: 345920230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/02/2026 Section Cited CCR 87468.1	1 2 3 4 5 6 7	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: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator stated he disabled the locking mechanism immediately upon finding out about it. Licensee/Administrator agrees to conduct staff training with current staff to ensure this does not occur again. Topics will be on personal rights and elopement prevention. Documentation of staff training to be provided to the Department by 6/2/26.
	8 9 10 11 12 13 14	Based on interviews conducted, the Licensee did not ensure that staff (S2) did not place a lock on (R1's) door at night, for approximately a week, which presented a potential personal rights violation. The locking mechanism was placed on/around the end of May 2025 or beginning of June 2025,	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/21/2026 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20260421151442

FACILITY NAME:	CITRUS HEIGHTS SENIOR LIVING		FACILITY NUMBER:	345920230
ADMINISTRATOR:	SAHOTA, SUKHMAN		FACILITY TYPE:	740
ADDRESS:	8440 EDGECLIFF COURT		TELEPHONE:	(916) 716-5999
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	05/19/2026
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Sukh Sahota, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff did not prevent resident from wandering from the facility.

INVESTIGATION FINDINGS:

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The allegation states that (R1) would sometimes break out of their room and leave the facility.

The results of the investigation as as follows:

Resident (R1) moved to the facility on March 17, 2025 with a primary diagnosis of Alzheimer's Dementia. The Physician's Report notes that (R1) could be confused/disoriented, exhibits wandering/sundowning behaviors and is an "elopement risk".

The Department was not provided with specific dates/times of when (R1) allegedly left from the facility. The Administrator stated that (R1) would often go to the front door and open it; however, upon hearing the alarm sound, would get startled and allow staff to redirect them. The Administrator stated (R1) would try to often exit the facility, and at different times of the day, after moving to the facility in March 2025, but is attempting to exit much less frequently currently.
*cont on 9099A-C-1..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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 5

Control Number 59-AS-20260421151442

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: CITRUS HEIGHTS SENIOR LIVING	FACILITY NUMBER: 345920230
	VISIT DATE: 05/19/2026

NARRATIVE

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9099A-C-1.. The administrator confirmed that (R1) has a diagnosis of Dementia and only exited the door on one occasion, on March 31, 2026, (around 12:00 pm) when he was on the phone requesting emergency medical services for staff (S1). The administrator explained the paramedics had just arrived and saw (R1) who had just walked out the door and the fireman asked (R1) if they were okay. A neighbor was outside near the driveway, recognized (R1), and stayed with them for (2) minutes or less, until the administrator came outside. The administrator confirmed he had (3) total residents at that time, and he was the only staff on shift.

A family member of (R1) was asked if (R1) ever left the facility unassisted and stated "No, (R1) never left unattended that I'm aware of" and insisted that (R1) "never went in the forest " across the street but explained that (R1) has an "outside contractor" through a third party that takes (R1) to the movies every other week. The family member explained that on the last outing with one particular caregiver, (R1) "didn't want to go to the movies with him", got out of the car and went to the forest area across the street". The family member explained that this outside caregiver "didn't even go get (R1) but went to tell the caregiver in the facility", who went across the street to get (R1). The administrator stated that when this incident occurred, the outside caregiver signed (R1) out of the facility before getting in the car.

Staff (S1 and S2) were not available for an interview. (R1) indicated that they like to go to the forest but was not able to provide LPA with additional information. Another current resident (R3) stated they have "never seen (R1) leave or try to leave" the facility and confirmed there are auditory alarms on each exit door.

The administrator tested the front door door alarm on April 21, 2026 during the inspection, and. LPA heard the alarm sound. LPA also heard the alarm used at nighttime, which was significantly louder.

Based on information obtained, the allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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.

Exit interview. Copy of report provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

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