347001498-4-30-2024-59-AS-SCAA-D4U3B2-20240430180538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 04/30/2024
Date Signed: 04/30/2024 06:05:43 PM

Document Has Been Signed on 04/30/2024 06:05 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 TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	TONI JONES		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 41	DATE:	04/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Toni Jones, Administrator		TIME COMPLETED:	06:00 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 required annual inspection. LPA met with Toni Jones, Administrator, and explained purpose of inspection. Also present was Ashley Stahl, Resident Care Coordinator, and multiple other staff. The facility is licensed for (45) non-ambulatory residents who have a diagnosis of Dementia, (12) of whom may be bedridden, and has a hospice waiver for (17) residents. There are currently (6) residents on hospice. There is a pending increase for (4) additional residents. LPA will conduct an inspection once it is approved by local fire department. LPA and the Administrator toured the interior and exterior of the facility including the common areas, (2) resident rooms, medication room, dining rooms, activity room, salon, kitchen and staff lounge. LPA observed the facility to be clean, in good repair, odor free and the bathrooms to have paper towels, soap, trash cans with lids. LPA observed a 20-second hand-washing poster above each bathroom and kitchen sink. Fire extinguishers observed throughout and were last serviced on 7/24/23. There are (3) exit doors, including the front entrance door, equipped with an egress door alarm. Alarms and pendant cords are checked weekly for correct functioning. One exit door was tested and the alarm sounded. There is an enclosed courtyard with seating for residents. The inside temperature measured 72F. Hot water measured 108F in one resident room and 114F in another. There is sufficient 2+ day perishable and 7+day non-perishable supply of food in the kitchen and the refrigerator/freezer temperatures are recorded daily. Residents do not have access to the kitchen area where sharps are kept. There are (2) activity calendars posted for the month and activity staff will document resident's daily participation in each activity. LPA reviewed (8) resident files. Files were organized and contained current physician's reports and care plans completed within the last (12) months. Medications were reviewed for (2) residents. Orders matched medications being given and medications are being documented when received, when given as a scheduled or PRN medication, and when destroyed or returned to the family. cont on 809C-1...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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: 04/30/2024

NARRATIVE

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809C-1... The medication room and medication carts were organized and there are (2) Med-Techs on the 'am" and "pm" shifts. Weekly medication audits continue to be conducted by both internal and external nurses. Each medication cart has a complete First Aid kit.

LPA reviewed (8) staff files. Files contained all the required documentation. Staff have completed the initial and/or continuing required training and documentation was on file or printed during today's inspection. All staff is cleared and associated. Paperwork was submitted in August 2023 to renew Administrator's RCFE certificate (#6053689740- exp 9/11/23) and is pending renewal. Administrator to ensure staff renew their CPR certifications, if needed. All staff have current First Aid certifications.

The Infection Control Plan was reviewed along with the Emergency Disaster Plan binder. Administrator printed a blank LIC610E (9 page version) during today's inspection to be completed as supplemental documentation to the plan. Administrator to post visiting hours in the reception area.

LPA obtained current copy of liability insurance. LIC308 is posted and has not changed. LPA requested an updated copy of the LIC500, or staffing schedules (for May) be provided to the Department by 5/8/24.

There were no deficiencies observed during today's inspection. There is a Technical Advisory note being issued.

Exit interview. Copy of report left.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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