<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 12/05/2023
Date Signed: 12/05/2023 04:44:36 PM


Document Has Been Signed on 12/05/2023 04:44 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: 44DATE:
12/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on some concerns brought to the Department. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA also discussed an incident report recently received for an incident occurring on 11/23/23 for the same resident (R1).

LPA spoke to R1's family member who indicated that the facility did not inform them of a change in condition for (R1) and did not complete a specimen kit as requested. LPA discussed the concerns with both the Administrator, Resident Care Coordinator (RCC) and (3) caregivers/Med-Tech staff. LPA reviewed the Medication Administration Record (MAR), and the Bowel Movement log for November 2023

Interviews confirmed that (R1) did have some random and inconsistent changes in her bowel movements during the last month, did not have any symptoms of illness, such as a fever, and Med-Techs were made aware of the changes; however, the Bowel Movement log documentation did not reflect these changes. The log notes from 11/28/23- 11/30/23, (R1) was noted to have "loose bowel movement". The Administrator stated she began communications with family members on 11/29/23, Wednesday, after the change was noticed for (2) days. One of the family members obtained a prescription for Immodium on Thursday, 11/30/23, and it was delivered on Friday, 12/1/23, around 5:00 pm, which was confirmed by the family members. (R1) was administered (2) tablets on Friday, 12/1/23, and staff was instructed to add a note that (2) tablets were administered on 12/1/23, in the "pm" since it was authorized on 11/30/23. Family member was also upset that only (1) specimen container was completed instead of (4). Both the Administrator and RCC stated there were only (3) specimens and there was not an order for staff to complete the test kit. The Med-Tech who was given the test kit stated she was handed the kit from another staff member with no instructions, no order, and had not received any training on how to complete the specimen sample. Nevertheless, the Med-Tech staff and another care staff were able to obtain one specimen container, as requested by the Administrator.

Based on information obtained, it appears the facility acted promptly when (R1) was observed to have a change in condition and continues to be in contact with the family. There are no deficiencies issued in this report. Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1