347001498-10-17-2023-59-AS-MSEY-CWQNXZ-20231018105158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:08:32 PM

Unfounded

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
07/18/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230718114857

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	EDITHA MCCULLOUGH		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 45	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Toni Jones, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee is not following reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/18/23, for the above allegation. LPA met with Toni Jones, Administrator, and explained purpose of inspection.

During the investigation, LPA discussed the allegation with the current Administrator, Interim Administrator, Resident Care Coordinator (RCC), (4) staff and reviewed the Incident Binder. Administrator reviewed staff training on the computer and confirmed that all staff have completed coursework in Abuse, Neglect and Explotation in an Elder Care Setting and Resident Rights, Personal Rights and Ethics. Mandated reporting is discussed in these (3) courses.

Allegation: Licensee is not following reporting requirement.
The complaint alleges that a manager told staff last week not to report, and incidents are not being reported as required. There are no specifics included in the complaint and the complainant is anonymous.
cont on 9099C-1..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230718114857

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: 10/17/2023

NARRATIVE

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9099C-1... The RCC stated on 7/20/23 that staff will call her if there is a serious incident and she will then let the Administrator know, who will review the incident reports and send them in. The Interim Administrator confirmed on 7/20/23 that she reviews the incident reports provided to her from staff before submitting them to the Department. The RCC stated on 10/17/23 that she has never disposed of incident reports given to her by staff and she talks about the importance of Mandated Reporting in staff meetings. Additionally, the RCC indicated that staff will complete "individual 1:1 training" in her office on the computer. LPA received information that a prior Administrator would sometimes tell staff not to report incidents to the Ombudsman, and to the Department, but that staff would still report since they are mandated reporters. This was prior to May 2023.

The current Administrator stated that she was trained that the person observing the incident should be the one reporting and completing the incident report. She will review the report before sending it to the Department and has never seen any manager or staff rip up an incident report. The current Administrator indicated she will take the internal notes from the incident and write the incident report to be submitted to the Department.

One staff stated on 10/16/23, that he and other staff were told at staff meetings that staff “should know what to report and to tell a lead, Med-Tech, staff, but if the incident is unwitnessed, staff can’t write a report if they have not witnessed the incident. A second staff interviewed stated she has never been told personally not to report incidents, has completed training on mandated reporting, and has been talked to in a group by managers. This same staff confirmed she only completes an incident report for what she personally observes and will ask a caregiver to complete a report if he/she has witnessed an incident and then provide that report to her. This same staff stated staff will place the completed incident report under the RCC and Administrator's door and has no way of knowing if the incident ever got reported.

Two (2) additional staff stated that they have received training on being a mandated reporter, with one staff confirming she has completed incident reports before. The second staff stated she has observed incidents with other staff present and those staff have completed the incident report and included her name on it. All staff interviewed stated they would not listen if they were told not to report an incident since they are mandated reporters. LPA reviewed the incident binder and observed each month to contain copies of multiple incident reports submitted to the Department.

Based on information obtained, LPA finds the 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.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

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