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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:48:41 PM

Substantiated


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
12/26/2023 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20231226105149
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
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff did not ensure medications are dispensed as prescribed for resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete an investigation and provide findings to a complaint received on 12/26/2023. LPA met with Toni Jones, Administrator, and explained purpose of inspection.

During the investigation, LPA conducted multiple interviews, including with the facility Administrator, Resident Care Coordinator, (4) med-tech/caregiver staff, and resident’s (R1) family member. Various documentation was reviewed, including, but not limited to, Medication Administration Record (MAR) for November/December 2023, PRN medication logs, prescription medication orders, Bowel Movement Logs, incident reports and hospital discharge paperwork. Resident (R1) resided at the facility from January 2023 through February 2024.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 59-AS-20231226105149
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: 03/13/2024
NARRATIVE
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9099C-1. Allegation: Staff did not ensure medications are dispensed as prescribed for residents in care. The complaint alleges that staff did not administer resident (R1)the medication, Loperamide (Imodium), as prescribed.

Interviews with resident's family member and facility staff confirm that resident had irregular episodes of loose stool or diarrhea in November 2023. The Bowel Movement Log for November 2023 documents loose stool and diarrhea from 11/10/23 through 11/30/23, with diarrhea noted on (3) consecutive days from 11/28/23 through 11/30/23. Resident obtained a prescription for Loperamide (Imodium A-O) 2 mg oral tablet on 11/30/2023 with orders to Take 2 tablets by mouth after the first stool, then 1 tablet after each subsequent loose stool. Do not exceed 4 tablets in 24 hours. Take with 4 to 8 ounces of water.

The MAR documentation for December 2023 shows the initial (2) tablets of Loperamide 2mg were administered on 12/1/23 on the “pm” when it arrived. Staff initials were made on the MAR several more times for 12/1/23 and 12/2/23 with a note added that (2) Imodium tablets were not administered on 12/2/23, as signed. Also, both the scheduled and PRN prescription are listed as a “PRN", and there was a notation on the MAR that dosages were to be recorded instead in the PRN Binder.

A notation was made on the PRN log that on 12/3/23 (8:00 pm) (1) tablet of Loperamide 2mg was administered and was “not effective”. The PRN log notes that the next dosage was administered on 12/5/23 (2:00 pm) and (2) tablets were given prior to resident leaving the facility with a family member. The next PRN dosage of (1) tablet, was given on 12/7/23 (1:00 pm), but there are no notes if the medication was effective.

The Bowel Movement log shows that resident was also given foods known to help with diarrhea (BRAT diet) on 12/8/23, but there was "still no change" after resident was given (1) Imodium tablet earlier on 12/8/23. The PRN log documents that (1) tablet was given on 12/8/23 (9:00 am) and it was "not effective".

On 12/28/23, the Administrator reviewed the PRN log with the LPA and confirmed Imodium was given at 9:00 am on 12/8/23 and resident didn't have another episode of diarrhea for (17) hours, until 2:00 am on 12/9/23. The BM log notes resident had a large episode of diarrhea but was not administered Imodium following this episode. The Administrator commented that the NOC shift staff also didn't log the 2:00 am episode of diarrhea on the Bowel Movement Log, so she made the notation. Resident Care Coordinator stated this NOC staff had taken a break from working at the facility, and the log was implemented during her absence.

*cont on 9099C-2.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20231226105149
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: 03/13/2024
NARRATIVE
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9099C-2... The family member stated that resident had "more diarrhea on Saturday, 12/9/23 at 2:00 am and then again on 12/9/23, 8:00 am”, was not given Imodium following these episodes.

The Administrator stated that resident was sent to the emergency room on the morning of 12/9/23 due to having continuous episodes of diarrhea for (3) consecutive days. The Administrator met (R1) at the hospital and stayed with resident until she returned to the community.

Resident’s family member stated that, prior to resident going to the Emergency Room on 12/9/23, she had informed facility staff that resident had tested negative to several lab tests and blood panels ordered by her primary care physician and was on the list for a gastroenterologist referral.

The facility submitted an unusual incident to report resident was sent to the Emergency Room on 12/9/23, at 8:20 am for consistent diarrhea for the prior (3) days. The Administrator did not administer the medication following this episode to seek clarification from a physician since the diarrhea had persisted for (3) days continuously, despite being given the medication.

Resident returned the same day and the hospital discharge paperwork shows resident was treated for diarrhea and given care instructions to continue taking Imodium, as directed, follow up with primary care physician and schedule to see a gastroenterologist for further evaluation.

After returning to the facility late afternoon on 12/9/23, resident was given (1) tablet of Imodium due to having diarrhea at the hospital, and the PRN log documents (1) tablet was administered on 12/9/23 (4:30 pm) and it was effective. Documentation reviewed shows resident did not need to be administered a subsequent Imodium tablet until the morning of 12/11/23 and resident left with family member, so it's not clear it the medication was effective. Resident received the next table in the evening of 12/12/23 (7:28 pm), where it is noted as being effective.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.



Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
12/26/2023 and conducted by Evaluator Sabrina Calzada
COMPLAINT CONTROL NUMBER: 59-AS-20231226105149

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
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Licensee did not ensure staff had access to a working facility telephone.
Staff did not ensure the care needs of residents are being met.
INVESTIGATION FINDINGS:
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During the investigation, LPA conducted multiple interviews, including with the facility Administrator, Resident Care Coordinator, (4) med-tech/caregiver staff, and resident’s (R1) family member. The results of the investigation are as follows:

Allegation: Licensee did not ensure staff had access to a working facility telephone.
Complaint alleges the facility did not have a working phone at the facility during the early evening on 12/22/23 and during the night shift on 12/24/2023.

Resdident’s family member stated she tried calling the facility land line on Friday, 12/22/23 (7:00 pm) and on Sunday, 12/24/23 (9:00 pm) and no one answered the phone and later found out that a Med-Tech had locked the porta phones in the office to charge.

cont on 9099A-C-1...

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20231226105149
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: 03/13/2024
NARRATIVE
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9099A-C-1... One caregiver staff stated on 12/28/23 she usually doesn't hear the phone ring or the door bell sound because she is in resident rooms, and the television and music are on. This staff stated she thinks it's "one phone" only that is used after 5:00 pm, and confirmed that Med-Techs should be answering the phone and caregivers will answer, if needed, commenting she carries her personal cell phone with her, only checks her phone on breaks, and the facility does not give care staff a phone during their shift.

The Administrator confirmed that the land line phone is working, and the phone is "always in the reception area". On 12/28/23 (3:00 pm), LPA observed the phone to be at the reception desk and the dial tone to work when the handset was picked up. The Administrator stated the cordless phones (2) were charging at a time but were never locked up and confirmed she had both agency staff and facility staff working the NOC shift on 12/24/23- 12/25/23.

The Resident Care Coordinator (RCC) stated the receptionist works from 9:00 am - 5:00 pm, answers the front desk phone, and there are also (3) cordless phones that use "one line" only. The RCC stated "the Med-Tech always has a cordless phone- but there are certain places in the building where the reception isn't as good", explaining there have been multiple different cordless phones used, and this problem has been encountered with each phone used.

A Med-Tech Staff, stated the desk phone is always on the desk but staff will sometimes"disconnect it so clients can't use it" if they are in the front common area. This staff stated she will bring out the (3) cordless phones and the Med-Tech always has one, and although there are (3) phones, there is only (1) phone line. If a second line is needed, staff can use the reception line. This staff explained the cordless phones were replaced a few months ago, the new ones hold the charge better, callers can leave a voice message 24/7, and staff can still hear the phone ringing even if staff is on another line.

This same staff stated she is not aware of a time when the cell phones were locked in the RCC's office or medication room time and were being charged and not available for staff use and commented, in general, staff do not receive calls during the NOC shift unless a resident is returning from the hospital and pharmacy deliveries end at midnight.
cont on 9099A-C-2..
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
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20231226105149
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: 03/13/2024
NARRATIVE
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9099A-C-2.. A second Med-Tech, who worked in December 2023, stated there is always a working phone at the facility, 24/7, and when she was scheduled on shift, she would ensure the reception phone was on the reception desk, as there are (2) main residents who commonly use the phone to call their families. This staff explained how the cell phones can't be used while they are charging, but they will still ring and usually the Med-Techs will keep (1) phone with them during their shift so they can answer the phone.

The Med-Tech stated that at 7:00 pm, Med-Techs are usually doing a medication pass but "staff can hear the voice mail when someone is leaving a message" and if there is no answer, it’s because someone is probably using one of the three phones. (R1's) family member stated she "possibly" left a message when trying to contact a staff member one of the times.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Allegation: Staff did not ensure the care needs of residents are being met. Complaint alleges that staff were not tending to resident's (R1) care needs at night, on 12/24/23, including monitoring resident for changes, while she was screaming for help while in pain.

Resident’s (R1) family member stated when she arrived at the facility on 12/24/23 at approximately 9:30 pm, she could hear resident screaming from the hallway and when she arrived at resident's room, she saw her laying in bed, indicating it "hurts" behind her neck. Resident’s family member stated she talked to staff, (S1) who attempted to call the RCC twice, and there was no answer, so resident’s family member then texted and called the Administrator who arrived around 11:00 pm.

(S1) confirmed she worked on the evening shift on 12/24/23 and stayed with resident (R1) in her room for 20 minutes that night, watching TV, and resident did not scream or ask for any pain meds during this time. (S1) indicated that (R1) never complains of pain and sometimes will call (S1) because she doesn't want to be alone and likes to listen to country music. (S1) stated she checks on all her assigned residents during her shift and she and other staff will brush residents' teeth in the morning and at bedtime.

cont on 9099C-A-3...

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
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20231226105149
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: 03/13/2024
NARRATIVE
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9099C-A-3... The Administrator stated the typical baseline for resident (R1) is to say "God help me..." over and over and (R1) doesn't normally say she is in pain. LPA observed text messages from resident’s family member to the Administrator on 12/24/23 stating resident was in pain. The Administrator commented that resident's family member "didn't initially say (R1) was screaming" but said that in later texts.

The Resident Care Coordinator(RCC) stated "the only time I've ever heard (R1) complain of pain was in her stomach due to the diarrhea". The RCC confirmed she was at the facility on 12/24/23 and (R1) was sleeping some of the time, explaining that around 8:45- 9:00 pm, resident "was a little upset because she felt alone in the room- her roommate was sleeping". RCC indicated that staff, (S1) was the caregiver and she passed the "pm" meds, as RCC. RCC commented "just after 9:00 pm, (R1) fell asleep" and then she was fine, without any pain, when the Administrator saw her at 11:00 pm.

RCC confirmed that (R1) used to scream until she started taking Trazadone 1-2 months ago, indicating that resident takes (1) routine Trazadone and (1) PRN Trazadone. RCC commented that (R1) used to wake up all night long, and that's why Melatonin was started; however, resident did not ever complain of pain and would say nothing hurts when she was asked.

LPA interviewed a second staff (S2) who confirmed she worked "am" shift on 12/24/23 and (R1) was not in any pain that she was aware and resident went out of the community with a family member during her shift. This staff stated (R1) has "not recently been crying in pain" and resident "mostly cries out for help, after she has just woken up from being asleep. (S2) stated "it really depends" on if (R1) is experiencing "loneliness" as her roommate doesn't talk. (S2) commented that before (R1) started taking Melatonin and Trazadone, she would regularly wake up at 2:00 am but has been sleeping through the night since starting the (2) medications.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20231226105149
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by:
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Licensee/Administrator have already completed staff in-service training for PRN medications and documentation on the PRN log and MAR.
Documentation of training completed in February 2024 and later by 3/14.24.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure resident (R1) was administered PRN Loperamide 2 mg (Imodium), as prescribed, on 12/9/23 (2:00 am) and following diarrhea, which posed a potential health and safety risk to residents in care. (R1) was sent to the emergency room for further evaluation.
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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
LIC9099 (FAS) - (06/04)
Page: 8 of 8