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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 04/16/2024
Date Signed: 04/16/2024 12:24:03 PM


Document Has Been Signed on 04/16/2024 12:24 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:
04/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Editha Mc CulloughTIME COMPLETED:
12:25 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 related to a recent AWOL involving resident (R1) on April 6, 2024. LPA met with Editha McCullough, Administrator Designee, and the stated reason for inspection.

During today's inspection, LPA and the Administrator Designee observed the exit door and exit Egress gate where (R1) exited on 4/6/24 at approximately 5:10 pm. The door alarm was tested and (2) staff were promptly observed to be responding to the alarm sound. LPA observed a new alarm device to be installed on the top of the door. The Egress exit gate alarm was also tested and sounded for (15) seconds before the gate opened to the parking lot.

The AWOL was reported by phone by the Regional Director on 4/10/24. A written incident report was also submitted on 4/10/24. It was determined later on 4/6/24, by a fence company, that resident (R1) was able to leave the facility unnoticed due to the audible sound only being heard in the main lobby area, and not throughout the facility. The egress gate was confirmed to be perfectly functioning. Resident was returned by the police at approximately (20) minutes later, at 5:35 pm, and resident sustained no injuries.

Staff received follow up training on 4/8/24 and 4/9/24 relating to resident elopement procedures, delayed egress and re-arming a delayed egress lock after it's used. Additionally, an additional auditory alarm and a strobe system will be installed in another location to help staff hear when an alarm sounds.

Resident (R1) is not able to leave the building unassisted due to a diagnosis of Dementia.

Per Title 22, Division 6, Chapter, 8, the following (1) citation is issued on the 809-D page. A Technical Advisory Note is also being issued.

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: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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 2


Document Has Been Signed on 04/16/2024 12:24 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: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
87705(j)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia.
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee/Administrator immediately trained all staff on delayed egress, elopment procedures and re-arming a delayed egress lock after each use. In addition, an auditory alarm as well ass a strobe system will be installed in another location in the faciltiy to assist staff hear when an alarm is activated.
8
9
10
11
12
13
14
Based on interview conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on 4/6/24 (5:10 pm approximatey), which posed an immediate health and safety risk to residents in care. Resident was returned to the facility, uninjured, 20 minutes later, at approximately 5:35 pm.
8
9
10
11
12
13
14
Documentation of training to be sent to CCLD by 4/17/24. Photo documentation to be provided to CCLD showing that an additional auditory alarm and stobe lights have been installed.
Due by 4/30/24.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2