347001498-11-1-2023-59-AS-MSEY-CXBUQD-20231106144655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 11/01/2023
Date Signed: 11/01/2023 05:15:56 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
10/31/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20231031105239

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	TONI JONES		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 44	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Toni Jones, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not provide medical attention for residents in a timely manner.
Staff do not ensure that residents have adequate toiletry supplies.
Staff did not prevent an outbreak of scabies.
Resident was left soiled for extended period of time.
Staff not providing adequate food service to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received anonymously on 10/31/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection.
During today's inspection, LPA discussed the allegation(s) with the Administrator, (3) caregiver staff, and (2) culinary staff. LPA interviewed (4) residents, including resident (R1), as best possible. LPA reviewed the visitor log for October 2023 and the Scabies Infection Line List provided to the county for (4) positive cases in October 2023. LPA also toured common areas and individual resident rooms. The results are as follows:

Allegation: Staff did not provide medical attention for residents in a timely manner.
The complaint alleges that a resident was heard screaming after falling in her room on 10/31/23, and staff left the resident on the floor after discovering she had fallen. The complainant provided a first name only for this resident.

**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: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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

Control Number 59-AS-20231031105239

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: 11/01/2023

NARRATIVE

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9099C-1... The Administrator confirmed there is not currently a resident with this first name and described a recent incident when resident (R1), who has a similarly sounding first name, slid off her bed, which is low to the ground, and onto a fall mat, on 10/29/23, at approximately 2:50 pm. The Administrator stated (R1) will yell for staff if she needs assistance, and staff attended to (R1) immediately after she fell and did not observe any bruising or injuries at that time.

The Administrator stated that staff sought immediate medical attention via triage over the phone with resident's health care provider, and it was determined that resident did not need any further medical intervention. LPA discussed the incident with (R1) on 11/1/23, who denied having a recent fall and couldn't confirm if she feels any pain. One staff who was interviewed stated "(R1) might have fallen two months ago" and was not aware of a recent fall indicating she is not currently assigned to care for (R1).

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.

Allegation: Staff do not ensure that residents have adequate toiletry supplies.
Complaint alleges there were no supplies such as wet wipes in (R1's) room to assist with incontinence care and also there is no soap/ body wash, toothbrush/tooth paste or lotion in (R1's) room.

The Administrator stated that in the beginning of October 2023, she changed the type of disposable wipe staff use to provide incontinent care and showed LPA the dry wipe used previously that required staff to moisten it with a cleansing spray before each use. LPA also observed the pre-moistened wipes currently being used in green packaging. LPA spoke to staff who had just provided incontinent care to (R1). Staff confirmed that they always use wipes when providing care, as they are trained to do so and that they will use a caregiver cart with a bag containing wipes, gloves, and trash bag liners in it. LPA observed the carts with the bag hanging on the outside for easy access. (R1) indicated she receives assistance when needed from staff.

LPA observed a package of green wipes in random resident rooms and staff indicated that hospice residents will also have wipes in the room for hospice staff to use. The Administrator stated the Maintenance Director is in the process of placing packages of wipes in each resident room.
***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: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20231031105239

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: 11/01/2023

NARRATIVE

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9099C-2...The Administrator stated that as a general rule, hygiene products are not kept unsecured in resident rooms or bathrooms, due to all residents having a diagnosis of Dementia, and that staff will regularly scan resident rooms for hygiene products hospice staff leave behind daily. LPA did not observe any hygiene products left out unsecured and within resident access. The Administrator confirmed that all hygiene products are kept either locked in the laundry area or in the resident drawer in the room with a clip lock. LPA observed that several resident's hygiene supplies are centrally stored for their safety. The Administrator confirmed that resident families will provide hygiene supplies to the facility.

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.

Allegation: Staff did not prevent an outbreak of scabies.Complaint alleges the facility had a scabies outbreak and (2) resident names (R2 and R3) who share a room were provided.

The Administrator provided LPA with a copy of the Scabies Infection Line List submitted to the county health department for (4) positive cases reported in October 2023. The Administrator confirmed that (R2) never tested positive for scabies, and (R3), who shares a room with (R2) did test positive. The Administrator confirmed all residents just started back attending their health care day program this week after a 2 week, 4 day postponement, and it is thought that the scabies was brought into the facility from contact at the day program. Additionally, there are no staff ever tested positive. The Administrator indicated she remains in weekly communication with public health for further monitoring through 11/30/23. This allegation was previously investigated and found to be UNFOUNDED on 8/18/23.

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.

Allegation: Resident was left soiled for extended period of time.The complainant alleges they have observed facility staff not properly cleaning residents and not using wipes.
All staff interviews confirmed that staff provide timely assistance when a resident needs incontinent care. LPA observed staff to be finishing up providing incontinent care to (R1) and to other residents during today's inspection. There is no information provided as to the specific resident(s) the allegation pertains to. LPA did not observe significant incontinent odors present when touring and observed multiple caregiving and Med-Tech staff present.

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.
*cont on 9099C-3..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20231031105239

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: 11/01/2023

NARRATIVE

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9099C-3... Allegation: Staff not providing adequate food service to residents in care.
The complaint alleges that (R1) has complained the food is not served on time and it is often cold.

(R1) stated to LPA that when the food is cold, "I tell them it needs to be warmed". Staff interviews indicated that (R1) is served pureed food in her room and staff will hand feed her with a spoon. One staff stated "(R1) will always say the food is too cold, there is not enough flavor and it needs more sugar".

LPA interviewed (2) culinary staff who indicated that food is served hot to residents if it's supposed to be hot. One staff stated "residents will complain if the soup is too hot, but we never get complaints about it being too cold", commenting, "maybe the caregivers don't serve it fast enough".

One of the kitchen staff stated when preparing pureed food for (R1), she will take the food directly from the warm stove and place it in a blender. This staff stated that caregivers for (R1) will most often come to the kitchen to request sweets for (R1) more than for any other reason.

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.

These allegations are being dismissed without any citations being issued.

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: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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