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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:23:30 PM


Document Has Been Signed on 07/20/2023 05:23 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: 45DATE:
07/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Editha Mc Cullough, Interim Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the receipt of (2) incident reports (LIC624) on 7/19/23. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection.

LIC624's involve residents (R1 and R2) and an incident occurring on 7/18/23 at approximately 6:45 pm. LIC624's state that R1 hit R2 in the face but there were no marks, bruising or swelling on R2's face.

Interviews with Med-Tech staff (S1) who was present during the incident confirmed the reported information that R1 did actually hit R2 and this is not typical behavior and was an isolated incident. S1 showed LPA the necklace that was pulled off of R2 and stated she would be assisting in getting it repaired promptly.

S1 stated that R1 was sent out for a medical evaluation and returned the following morning with no new diagnoses or medication changes. S1 stated that both R1 and R2 have been walking around the community as they regularly do and will continue to have increased monitoring for the next two weeks.

Administrator stated that R2's conservator was notified and declined to have resident sent out to the ER due to no visible signs of injury. R2 was still evaluated by an ambulance provided immediately following the incident. R1's responsible person was also notified.

Administrator and S1 stated that residents can show "sundowning" behaviors in the evening and confirmed resident's (R1) care plan and assessment were updated. R1's service plan was reviewed and will be updated as needed.

The facility took immediate action in seeking medical attention and notifying the responsible persons.
There are no citations being issued on this report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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