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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:34:15 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
02/26/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240226123853
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:
03/28/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff sexually assaulted resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to an investigation conducted by the Department for a complaint received on 2/26/24. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. Also present was staff, Editha McCullough, who was reviewing staff files in the Administrator's office.

During today's inspection LPA conducted (5) staff interviews with both "am" and "pm" caregiver staff relating to other concerns brought to the Department's attention during the investigation.

During the course of the investigation, the Department conducted interviews with facility staff, resident (R1), resident's family member, local law enforcement and the Ombudsman and reviewed pertinent documentation.

The results of the investigation are as follows:
cont on 9099C-1...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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 3
Control Number 59-AS-20240226123853
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: 03/28/2024
NARRATIVE
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9099C-1...Allegation: Staff sexually assaulted resident in care. The allegation states resident (R1) was inappropriately touched by care staff (S1).

The complaint information received indicated that resident (R1) stated to her family member on 2/11/24 that staff had pushed her on her bed and "touched her"; however, the facility was not made aware of the incident until 2/23/24 when another family member spoke with the Administrator. The Administrator then notified the facility nurse who talked to the resident about the allegation. Out of precautionary measures, resident was immediately sent to the hospital to be medically evaluated; however, an exam was not done due to resident being non-verbal, unable to provide any details, and in denial that a sexual assault had possibly occurred.

Local law enforcement responded to the hospital and attempted to interview (R1) and then interviewed several staff, as requested by the facility. Documentation provided by local law enforcement supports there was no evidence to confirm or deny a crime occurred. Law enforcement also spoke to resident's family member who indicated the allegation was not conveyed to the facility Administrator sooner, due to miscommunication with staff. Administrator stated this family member did not communicate anything (R1)had told him on 2/11/24 or on 2/14/24 when he was in the building.

The Administrator stated to the Department that resident's spouse told staff, (S2) that staff (S1) had only "been mean to her" and there was no mention of a sexual assault. The Administrator stated to local law enforcement that she spoke to the other (3) staff working on 2/11/24, when the alleged incident occurred, and none of the staff observed any interaction between (S1) and (R1), as (S1) was assigned to a different hall from where (R1's) room is located.

The Ombudsman was interviewed on 3/5/24 and indicated (R1) was interviewed at length on 2/27/24 and no disclosures were made about a sexual assault. The Ombudsman stated resident was friendly and relaxed and was insistent that no staff had touched her inappropriately. Resident, (R1), was interviewed by different individuals, and denied being touched inappropriately each time. Due to resident's diagnosis of Dementia and rambling during the interview, this resident was not able to provide any useful information or respond appropriately to questions asked about living at the facility. Attempts were made to speak to (R1's) roommate (R2), but (R2) declined to speak to the Investigators.

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-2...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240226123853
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: 03/28/2024
NARRATIVE
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9009C-2.... Staff interviews were conducted on 3/28/24 for the following additional concerns reported:
(S1) was reported to be "rough" with not only, resident (R1), but other residents also.
One staff stated she recalls (S1) being rough when transferring residents, stating she observed several
Residents to show a look of discomfort on their faces. This staff stated she is not sure if (S1) was specifically rough with (R1). A second staff stated (S1) was "slightly rough", and would yell back at residents if residents began to yell at him or call him names. A third staff stated she never observed (S1) to be rough with (R1) or any other residents. A fourth staff who works on the evening shifts stated he observed (S1) to be "verbally rough maybe" with residents but never physically. A fifth staff interviewed didn't recall working with (S1). (S1) was an agency staff that did not continue working at the facility on/around February 2024.

Staff were observed to tell residents the kitchen is closed when a resident says they're hungry.
One staff stated she has not observed any staff to tell residents they can't have any food or snack and commented that an agency staff might have said the kitchen is closed. A second staff stated she never heard any staff comment that the "kitchen is closed" and a lot of residents have snacks that are stored in the kitchen for between meals. The third staff stated she will go to the kitchen and request a snack be prepared if a resident says they are hungry. A fourth staff stated he has heard registry staff tell residents the kitchen is closed, one or two times, when the snack cart was not left out by the cook at 7:30 pm. This staff explained that agency staff didn't know to ask the Med-Tech for keys to the kitchen to get the cart. A fifth staff stated staff will usually go and get a snack from the kitchen if a resident asks.

Staff have been observed to act impatiently with residents who can't feed themselves independently. One staff stated some residents need a lot of cuing but wasn't able to give any examples. Two additional staff stated it is not an issue with staff being impatient in the "am" shift. Two "pm" staff stated they have never seen staff act impatiently with residents and staff is "patient and kind".

Staff have been observed to "swat" residents on the backside, in a playful manner.
One staff stated she has seen one resident swat several staff in a playful manner, over the last month. A second staff stated there is one resident who complains about certain caregivers as some staff are less comfortable with changing residents than other staff. A third staff stated she has never observed any staff to "swat" a resident. Two "pm" staff stated they have never seen any staff "swat" a resident.

Due to a lack of the preponderance of evidence, the above additional concerns were found to be Unsubstantiated. 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: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3