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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:57:24 PM


Document Has Been Signed on 03/13/2024 03:57 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:
03/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for complaint # 59-AS-20231226105149 and met with Toni Jones, Administrator. LPA explained the reason for the inspection.

During the course of the investigation, LPA reviewed several unusual incident/injury reports (SIR) for resident (R1).

One SIR reports (R1) having an unwitnesed fall on 10/5/23 in the dining room at approximately 8:45 am. The report states that care staff reported that resident was upset and “having an expression” and trying to get out of the wheelchair. Afterwards staff observed resident had a bump on her forehead, she was sent to the hospital for further evaluation. Resident returned to the community the same day with the recommendation to follow up with her primary care physician in 4-7 days. Interviews with the Administrator and family member confirmed that the care staff (S1) who was with resident when she began to enter a behavior, left the resident unattended, to get another staff to assist, when resident fell out of her wheelchair and sustained bruising on her head and face.

Resident’s family member stated staff (S1) walked away from (R1) on 10/5/23 which caused her to fall on her face. The family member provided (2) photos showing a head injury on resident's right side, above the eyebrows, and clarified that when staff walked away, resident stood up and then fell flat on her face.

A subsequent incident report was submitted on 10/9/23 for an incident occurring on 10/8/23 (2:30 pm). (R1) was observed to not be at baseline and to be screaming so was given a PRN medication for pain. Resident was sent to the emergency room later in the day, complaining of pain, and was diagnosed with pneumonia and a concussion from the previous fall from 10/5/23. Resident was prescribed levofloxacin and placed on alert charting until returning to baseline.

*cont on 809C-1

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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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
VISIT DATE: 03/13/2024
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809C-1..§1569.626 Training requirements for direct care staff states in part:

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:
(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

LPA reviewed training records for staff (S1), who began working as a care giver on 6/28/23. The records document that (18) hours of training was completed from 6/28/23 through 7/4/23 and (1) hour was specific to Dementia care.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/13/2024 03:57 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: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2024
Section Cited
CCR
87705(c)(3)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

(A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
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(S1) is no longer employed at the facility as of February 2024. Licensee/Administrator to ensure that all care staff have completed the required initial and/or continuing training hours.
LPA to review training documentation during the upcoming annual by 4/30/24.
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Based on documentation reviewed, the Licensee did not ensure that staff (S1) had completed the required training related to Dementia care, which posed an immediate health and safety risk to residents in care.
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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: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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