<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 06/21/2023
Date Signed: 06/21/2023 12:33:05 PM


Document Has Been Signed on 06/21/2023 12:33 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:EDITHA MCCULLOUGHFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:45CENSUS: 43DATE:
06/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Editha Mc Cullough, Interim Administrator TIME COMPLETED:
12:30 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
Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to deliver findings to an investigation conducted by the Department relating to an incident from 4/16/2023. LPA met with Editha Mc Cullough, Interim Administrator, and Ashley Stahl, Resident Care Coordinator, and explained purpose of inspection. The Department conducted an investigation into the above incident where resident (R1) was pushed by resident (R2) when (R2) entered (R1's) room at approximately 8:00 pm. (R1) was sent to the hospital following the incident and diagnosed with an L3 vertebral compression fracture. Hospital records show (R1) was admitted on 4/16/23 and was discharged on 4/20/23 to a skilled nursing facility and returned on 5/12/23.

The Department conducted interviews with various staff, (R1) and family members and (2) other residents. (R2) was not able to answer the interview questions due to her cognitive diagnosis. All staff interviews concluded that R2 has never been aggressive towards other residents or staff prior to the said incident and (R2) regularly roams the memory care community and enters resident rooms. Interviews confirmed that staff did not witness the incident but were nearby in the lobby area and responded immediately upon hearing (R1) yell for help. Interview with (R1) revealed that prior to the incident on 4/16/23, (R1) did not have any concerns for his safety relating to (R2), as (R2) had never shown any aggression towards (R1). (R1) stated on 6/16/23 when interviewed by the Department that he feels R2 became upset and pushed him when he took the sock from her that she had taken from his dresser. R1's spouse (R3) who also resides at the facility, as well as (R1's) family member, expressed they did not have any concerns related to (R2) being aggressive towards (R1). The Resident Care Coordinator confirmed that a lock was installed on the door to (R1's) resident room that is able to be locked only from the inside and can be unlocked from either side.

Based on information obtained, the Department was unable to establish that (R1) sustained a back injury due to lack of care and supervision by the facility and finds the allegation 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.
Exit interview. Copy of report left with Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1