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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:06:58 PM


Document Has Been Signed on 04/24/2023 12:06 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:TINA PREWITTFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:45CENSUS: 44DATE:
04/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Tina Prewitt, Administrator TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to an incident that occurred on 4/16/23 between residents (R1 and R2). LPA received an incident report on 4/17/23.

LPA discussed the incident more with Administrator, Tina Prewitt. Current RCFE Administrator certificate shows Administrator's name as Tina D. Smith. LPA to change Administrator's name to Tina Newton-Smith.

Administrator confirmed that resident (R1) remains hospitalized due to a back injury and may return with a brace. Administrator indicated that resident (R2) returned the same day with antibiotics for a diagnosed UTI. LPA attempted to speak with R2 during today's inspection, but R2 was observed to be sleeping.

LPA obtained copies of paperwork from each resident's file and an updated LIC624 with the correct incident date.

There are no deficiencies issued on this report.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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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