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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 04/30/2024
Date Signed: 04/30/2024 06:02:09 PM


Document Has Been Signed on 04/30/2024 06:02 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: 41DATE:
04/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Toni Jones, Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a death report submitted for resident (R1). LPA met with Toni Jones, Administrator, and explained purpose of inspection.

The facility submitted an incident and death report to the Department on 4/25/24 for resident (R1). The reports note that resident was found unresponsive, but still breathing, on 4/24/24 at approximately 7:30 am. Resident's health care provider was contacted and instructed the facility to send resident out for further medical evaluation. The facility contacted an emergency services provider and provided the information they requested by phone, and the outside service provider determined they did not need to call 9-1-1 for the transport. The facility was notified by the hospital later in the day, on 4/24/24, that resident had passed at approximately 3:33 pm.

Because the resident was not under hospice care, the Department is requesting that a county death certificate be provided.

LPA requested and received resident's current physician's report and care plan on 4/26/24 from the facility. Page 2 of the LIC624 was provided today.

There are no deficiencies issued in this report.

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: 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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