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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 10/04/2023
Date Signed: 10/04/2023 01:36:54 PM


Document Has Been Signed on 10/04/2023 01:36 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:TONI JONESFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:45CENSUS: 43DATE:
10/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue (2) additional citations related to substantiated complaint findings (# 59-AS-20230504081443) delivered on 9/29/23. There were (7) allegations substantiated but only (5) citations issued. LPA met with Toni Jones, Administrator, and explained purpose of inspection.

The following (2) allegations were substantiated on 9/29/23 but were included in citations for (2) similar but separate allegations that were also substantiated.

The Department has determined that it is appropriate to issue (2) additional citations for the following allegations: 1- Staff mismanaged resident’s medication and 2- Staff misinformed resident’s family about resident’s hospitalization.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are being issued on the 809-D page attached.

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: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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Document Has Been Signed on 10/04/2023 01:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/05/2023
Section Cited
CCR
87507(f)

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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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Licensee/Administrator has already requested to consolidate (R1's) current pharmacy into another pharmacy that will deliver directly to the facility. Administrator will attempt to consolidate all medication distribution into one pharmacy provider.
Documentation to be provided by 10/18/23 of any consolidations .
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Basd on documentation review, the Licensee did not ensure that item #25- Medication Safety, (listed in the Resident Handbook) which reads: "Medications will be Centrally Stored and monitored by Community Staff ", was followed, which posed an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type B
10/18/2023
Section Cited
CCR87405(d)(5)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by:
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The Administrator who submitted the LIC624 is no longer employed at the facility. The current Administrator reviews all LIC624's prior to submission and will ensure their accuracy.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the prior Administrator included accurate information only on the LIC624 submitted to the Department on/around 4/27/23 for the incident ocurring on 4/26/23 regarding (R1) going to the hospital, which posed a potential health and safety risk to residents in care.
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There is no further POC action needed on this one.
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: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2