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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 07/31/2023
Date Signed: 07/31/2023 05:56:27 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
07/28/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230728133706
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:
07/31/2023
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Ashley Stahl, Resident Care Coordinator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not provide resident with medication as prescribed
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 Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. Also present in RCC's office was Ashika Bennanon, Med-Tech.

During today's LPA discussed allegation with RCC and Med-Tech staff. LPA stated the complaint received on 7/28/23 was filed anonymously and only references a male resident with no specific information as to the resident's name or room number. The complaint alleges a resident was administered narcotics,specifically Norco, incorrectly. RCC provided names of the male residents and stated that resident (R1) recently had a missing bottle of Norco (Hydrocodone) 325-5 mg, and R1 refuses medications and hospice is aware. Med-Tech stated that several of these residents take Lorazepam and one resident takes Morphine.

cont on 9099C1...
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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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 4
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
07/28/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230728133706

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:
07/31/2023
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Ashley Stahl, RCC TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff failed to notice a change in resident's condition
INVESTIGATION FINDINGS:
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Both the RCC and Med-Tech staff confirmed that resident (R1) has been on hospice for over a year and has been gradually losing weight. The anonymous complaint states that resident has had concerns with weight loss and mobility. There is no additional information provided.

LPA observed R1 to be sitting in his room, in a wheelchair, and watching television, after eating lunch on 7/31/23. LPA observed R1's lunch to have been almost entirely consumed.

LPA observed resident's binder showing his Hospice and staff confirmed that resident is seen regularly by hospice personel.

Based on information obtained during the investigation, LPA finds this allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview. Copy of report provided to Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20230728133706
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: 07/31/2023
NARRATIVE
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9099C-1... The Department received an incident report (LIC624) by email on 7/21/23 from the Interim Administrator reporting that a bottle of Norco was missing for resident (R1) from the medication room. The Log Book finder notes the bottle of Norco was logged on 7/14/23 (8:53 pm), by staff (S1), as received; however, there is no record of the medication on the Centrally Stored Medication and Destruction Record (LIC622).

LPA reviewed the Medication Administration Record (MAR) for R1 for July 2023 and observed the medication to have been last initialed as administered, twice daily, as ordered, on 7/17/23.

LIC624 reports that R1 missed one day of Norco medication on 7/20/23; however, there were no staff initials entered for days 7/18/23, 7/19/23, 7/20/23, noting the medication was either administered to or refused by the resident. Med-Tech staff stated a PRN prescription for Norco replaced the scheduled prescription effective 7/21/23. LPA observed notes on the MAR that scheduled Norco was discontinued on 7/22/23.

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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20230728133706
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: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct additional staff training on the 3-step process in logging narcotics for staff accountability.

Documentation of staff training (agenda/attendees) due to the Department by 8/14/23.
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Based on documentation reviewed (LIC624 and medication documentation), the LIcensee did not ensure that resident (R1) was administered Hydrocodone (Norco) 325-5 mg table from 7/18/23-7/20/23), due to a bottle of the medication missing, which posed an immediate health and safety risk to residents in care.
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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: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4