347001498-10-17-2023-59-AS-MSEY-CWQNZT-20231018105453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 10/17/2023
Date Signed: 10/17/2023 05:22:56 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
07/25/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230725143417

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:	03:00 PM
MET WITH:	Toni Jones, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff are falsifying residents' records.
Staff are not providing residents activities of daily living (ADL's).

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 7/25/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection.

During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) Med-Tech staff and (1) caregiver staff. LPA reviewed the Narcotic Shift Count log from April- August, 2023, and the Controlled Substance Record from January- August, 2023. LPA also reviewed the October shower log. The results of the investigation are as follows:

Allegation: Staff are falsifying residents' records. The anonymous complaintant alleges the narcotic count was off, and he/she was told to correct it when it wasn't that staff that made the mistake.

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)

Page: 1 of 3

Control Number 59-AS-20230725143417

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... A Med-Tech staff stated that prior to May 2023, she was told to sign the narcotic log that the count was correct, even if it was off by one or two tablets. This staff stated the narcotic count could regularly be "off" by one or two tablets for a resident or two and that record keeping is much better now. The RCC stated that staff would tell her if the narcotic count was off and she would inform the prior Administrator who stated she would "look at it". LPA reviewed the Narcotic Shift Count documentation and observed it to be complete- and "none" was written in most spaces where any discrepancy is noted. There were no notes indicating the medication count was off. LPA reviewed the Controlled Substance Record where a date was entered when the medication was received and then each day it was administered. There were no noted errors based on the entries made on either documentation. There was no specific resident, medication or day/time referenced.

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.

Allegation: Staff are not providing residents activities of daily living (ADL's).
The complaint alleges that staff is asked to correct the ADL binders as well because there are holes and shows that ADLs are not being done.

A Med-Tech stated on 7/31/23 that everyday NOC shift will document when care is provided (i.e. incontinent checks) and will fill out logs only if there are issues or concerns, explaining that this is a new system that started a year ago. LPA asked this staff if the facility has enough staffing. This staff asserted, "it depends on the resident's behavior- it varies day to day". The staff stated there are (3) caregivers and (1) Med-Tech and that is "considered fully staffed" and staff will document both "End of shift logs" and shower logs for each resident.

The RCC stated on 7/31/23 "residents are getting showers- it is more of lacking of charting". The RCC explained that housekeeping staff has been trained on changing resident clothes to assist caregivers, and there are (3-4) caregivers and (1) Med-Tech scheduled during the daytime hours, and they will also schedule staff through an outside staffing agency. The RCC stated she has never instructed staff to "just sign the book" that the shower was given when it was not.

LPA was recently provided with documentation of the weekly narcotic audits being conducted, since 8/28/23, by the Administrator and the RCC. Additionally, the Administrator provided documentation of (2) other medication audits with an outside provider and pharmacy.
cont on 9099C-2...

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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Control Number 59-AS-20230725143417

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-2...On 7/31/23, LPA Calzada reviewed the July shower log/binder showing documentation for each resident. LPA observed that some days were signed by staff as having given a shower to the resident, and other days were marked "refused". On 10/17/23, LPA reviewed the October shower logs with the RCC for all residents and observed only a few scheduled showers to not have staff initials on the scheduled day.

The RCC and Administrator were certain residents received showers on many of these days and would discuss documenting better with staff. A Med-Tech staff stated that she was asked to just sign the ADL binder, when the month had ended, if there were scheduled showers that were not initialed as being given by staff on the log.

A caregiver stated that she is trained to initial the shower log binder at the completion of each shift to note which scheduled showers were given. This caregiver indicated she has never been told by lead or manager to just initial the shower was given when it was not. The staff explained that some residents definitely refuse showers and staff will do a "change of face" and notify the Med-Tech. This staff stated staff communication is much better now in recent months and resident concerns and issues are discussed more at the cross over meetings at shift change. There were no resident names or dates giving when the ADL's were allegedly missed.

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.

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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