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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 07/06/2023
Date Signed: 07/06/2023 05:37:49 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
06/29/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230629113804
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: 45DATE:
07/06/2023
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Editha Mc Cullough, Administrator TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff are not adequately supervising a resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection.

During today's inspection, LPA interviewed Interim Administrator, Resident Care Coordinator (RCC), and the Maintenance Director. LPA reviewed the incident report (LIC624) submitted to the Department on 6/30/2023 as well as resident (R1's) physician's report, care plan and other paperwork.
The results of the investigation are as follows:

Both the Administrator and RCC stated resident had just moved to the community on 6/29/2023 when he eloped later that evening, at approximately 7:30 pm. LIC624 states that resident was discovered missing by a med-tech who had entered resident's room to administer medications. All staff were immediately informed and began searching for the resident inside and outside of the community. ***cont on 9099C(1)..

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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-20230629113804
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 TERRACE
FACILITY NUMBER: 347001498
VISIT DATE: 07/06/2023
NARRATIVE
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9099C(1)...RCC, who was not working at 7:30 pm, was contacted by facility staff and she went to the nearby gas station and surrounding area and learned that resident had asked for directions to the bus station. RCC located resident while driving down Antelope Rd and returned resident to the community at around 7:50 pm, uninjured.

Resident stated to RCC that he "jumped the fence" in the outside patio area that faces the street.
LPA reviewed resident's care plan that was updated on 6/29/2023 with additional notes added regarding wandering and elopement during the evening/sun downing hours.

Physician's report, dated 6/26/2023, notes that resident is frequently confused and has increased agitation and confusion at night, due to sun downing, is not able to leave the facility unattended and needs constant medical supervision.

Extra staff have been monitoring the resident during evening hours, and the resident has not tried to leave the facility again. Resident's family and physician were notified of the incident with a request that resident's medications be reviewed for a possible adjustment to the evening dosages.

LPA observed the outside fence area where resident climbed over and observed an alarm on the patio door to sound when the door is opened. LPA spoke to Maintenance Director who confirmed that the batteries sometimes get low and they were replaced immediately following the incident on the (3) exit doors without a delayed egress alarm.

Based on information obtained and reviewed, 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, the following (1) citation is issued on the 9099-D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230629113804
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 TERRACE
FACILITY NUMBER: 347001498
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2023
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
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Maintenance Director stated on 7/6/2023 that the batteries in all (3) exit doors without a delayed egress alarm were replaced following the incident (AWOL) on 6/29/2023.

Administrator and Maintenance Director agreed to place a second working alarm on each exit door so it can be heard by staff and also conduct a staff elopement drill. Documentation of a second alarm being placed on the door to be provided to the CCLD by 7/7/2023.

Documentation of staff training for elopment drill to be provided to CCLD by 7/21/2023.
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Based on interviews conducted and observation, the LIcensee did not ensure that the auditory device on the patio exit door was working effectively, on 6/29/2023 (7:30 pm approximately) , to alert staff that resident (R1) had exited the the building, which posed an immediate health and safety risk to residents in care.
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Administrator stated she would discuss additional possible solutions with the Regional Director, including installing an outside camera on each patio, updating the pager system to include alerts from exit doors, use a Wanderguard bracelet on any resident(s) that has wandering tendencies.
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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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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
06/29/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230629113804

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: 45DATE:
07/06/2023
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Editha Mc Cullough, Administrator TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff did not prevent resident from being pushed by another resident.
INVESTIGATION FINDINGS:
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During today's inspection, LPA interviewed Interim Administrator, and the Resident Care Coordinator (RCC). LPA also spoke with the Ombudsman who investigated the incident pertaining to the above allegation. LPA reviewed the incident reports (LIC624) submitted to the Department. The results of the investigation are as follows:

Interview with Administrator and the RCC confirmed that the above incident occurred around 7:30 pm on 6/21/2023 between resident (R2) and resident (R3). Complaint alleges that a family member witnesssed the incident but upon review of the video footage the following day, only residents were observed to be present.
RCC stated that while R3 was trying to grab R2's clothing, R3 lost her balance and fell on the floor. RCC stated this was an isolated incident between these residents. RCC further stated that R3 uses a walker normally but was not using one just prior to the incident and staff responded immediately to the altercation upon hearing R3 yell. . **cont on 9099A-C1...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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-20230629113804
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 TERRACE
FACILITY NUMBER: 347001498
VISIT DATE: 07/06/2023
NARRATIVE
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9099A-C(1)... LIC624 states that R3 was taken to the ER for further medication evaluation since it was an unwitnessed fall and was prescribed Lidocaine for a scalp laceration. 48 hour alert charting was initiated following the incident for R2 and for R3 upon return from the hospital.

LPA interviewed the Ombudsman following her investigation of the incident on 7/3/2023. The Ombudsman discussed the incident with RCC who indicated she had viewed the video surveillance and was informed R3 fell and was not pushed by R2 and R3 did not sustain any substantive injuries.

The Administrator and RCC confirmed there were (4) staff working on shift during this incident. Med-Tech was administering night time medications and the (3) care staff were assisting with putting residents to bed. It is common that while staff is helping some residents, there are other residents who are sun downing in the common areas.

Based on information obtained, staff responded as quickly as they heard R3 yell, and staff was not able to prevent this isolated incident. LPA 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 to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5