347001078-3-22-2024-27-AS-KVIA-D3LT9L-20240322143206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001078
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:32:22 PM

Document Has Been Signed on 03/22/2024 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COURTYARD TERRACE		FACILITY NUMBER:	347001078
ADMINISTRATOR:	MAGDA LUIS		FACILITY TYPE:	740
ADDRESS:	3408 ALTA ARDEN EXPRESSWAY		TELEPHONE:	(916) 486-1281
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 40	TOTAL ENROLLED CHILDREN: 0	CENSUS: 38	DATE:	03/22/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Magda Luis		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/21/24, at 9:00 AM, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a self-reported incident. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The MedTech on duty called the DFA and provided LPA with the file for the resident who eloped (R1)1 to review while waiting for the DFA. On 03/20/24, this facility faxed a report to Community Care Licensing (CCL) that R1 eloped from the community at approximately 8:05 PM on 03/19/24. The report goes on to state the following: The alarms were set off and staff immediately went out to search the neighborhood for the resident. After 5 minutes, the Administrator was notified, after 15 minutes, the responsible party was notified, and the police were notified immediately after that. According to the report that CCL received, R1 was located at 8:30 PM and brought back to the community. LPA conducted a tour of the facility upon arrival. The delayed egress door on the right side of the facility was not alarmed when this LPA exited the building. The gate to the right of the door had broken zip-tie slipped through the latch. LPA opened the gate and an alarm sounded. Maintenance staff re-entered the patio area from the opened gate. LPA continued her walkthrough. The facility was clean and not malodorous. Residents were friendly and offered hugs and smiles. LPA observed 4 Caregivers, 1 MedTech, 1 Cook, and 2 Maintenance/Housekeeping staff workers. The DFA arrived and a brief interview followed. LPA obtained the following documents: LIC 500, LIC 308, LIC 602 dated 01/29/24, Needs and Services plans dated 02/13/24 and 03/21/24. ID/Emergency Contact Information, and documentation from Alpha One refusing transport to the hospital. LPA conducted a second

Stephen Richardson	TELEPHONE: (916) 263-4746
Kimberly Viarella	TELEPHONE: (916) 809-5764
	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTYARD TERRACE	FACILITY NUMBER: 347001078
	VISIT DATE: 03/22/2024

NARRATIVE

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walkthrough with the DFA and again exited the rear on the right side. The alarm was still deactivated on the door. LPA set the alarm off on the rear gate adjacent to that door. The DFA and LPA were able to walk from that area, through the outdoor patio, back inside and to the front of the building where the DFA turned off the alarm.

A review of records indicated that R1 was admitted to this memory care facility on 01/30/24, the LIC 602 stated that R1 was unable to leave the facility unassisted and R1 exhibited wandering behavior. The physician's report also stated that R1 was considered non-ambulatory based on their mental state. The facility was aware of the resident's wandering behavior prior to R1 being admitted.

This LPA reviewed the Needs and Services plans that were completed prior to the elopement and post elopement. Both stated that staff would redirect R1 in order to prevent elopements. No new strategies were listed in the updated Needs and Services plan. This LPA interviewed R1 and found R1 to be intelligent, alert, and well-spoken. R1 was very fit and guided this LPA on a walk through the common areas. LPA and R1 activated the alarm on the rear back gate and 3 staff responded within 11 seconds.

During the course of this investigation, this LPA learned that R1 has talked about or has tried to return home before but staff had previously been able to redirect R1. R1's behavior was not new, there was not a sufficient number of staff to meet the needs of this resident in care.

According to the California Code of Regulations, Title 22, this deficiency has been cited on the LIC 809D page and a Civil Penalty was assessed for $500.

On 06/12/25, this report was amended to change the citation from a violation of 87705(c)(4) under "Care of Person's with Dementia" to 87411(a) under "Personnel Requirements- General." A trainee (S3), without a walkie-talkie to communicate with coworkers, was sent to investigate the alarm. S3 had to go back to the other side of the building to inform the other staff that they could not locate the missing resident. Staff then had to determine which resident was missing before alerting the Administrator, the local police, the responsible party and Community Care Licensing.

A copy of this report was provided along with Appeal Rights and signed by the Designee, as the DFA was out of the building. Exit interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2025 12:03 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/12/2025 08:49 AM

Created By: Kimberly Viarella On 03/22/2024 at 01:22 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COURTYARD TERRACE	FACILITY NUMBER: 347001078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 06/13/2024 Section Cited	1 2 3 4 5 6 7	Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services... The licensee did not ensure that the above regulation was enforced as evidenced by:
	8 9 10 11 12 13 14	Based on a review of records, and inter- views, a trainee, S3 was sent, without a walkie-talkie, to investigate the alarm This demonstrated- ed a lack of competency with regard to personnel training. This posed an immediate threat to the health, safety, and/or personal rights of residents in care.	8 9 10 11 12 13 14	signature sheets of those who participated to community care licensing by the POC date.
	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:

Stephen Richardson

TELEPHONE: (916) 263-4746

LICENSING EVALUATOR NAME:

Kimberly Viarella

TELEPHONE: (916) 809-5764

LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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