347001498-2-23-2023-25-AS-MSEY-CPCV65-20230224150855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:45:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230118102646

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	TINA PREWITT		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	45	CENSUS: 45	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Tina Prewitt, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint report received on 1/18/2023. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, was screened per Covid-19 precautionary measures upon entering the facility and wore the following Personal Protective Equipment (PPE): surgical mask. The results of the investigation are as follows:

During the investigation, LPA interviewed the following facility staff: Administrator, Resident Care Coordinator (RCC), (2) caregiver staff, and (2) residents. LPA also interviewed (2) individuals who are employed by an outside health care provider. LPA reviewed facility documentation related to residents (R1 and R2) and medical documentation related to resident's (R1) injury referenced in the complaint report..

The results of the investigation are as follows:

cont on 9099C(1)...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230118102646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 02/23/2023

NARRATIVE

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9099C(1).. Allegation: Resident sustained unexplained injuries while in care.
Complaint alleges that resident (R2) yanked the necklace from around resident (R1's) neck which cut R1's left forearm.

Resident (R1) moved to the community on 8/4/22. Resident (R1's) physician's report, dated 8/2/22 notes that resident has Mild Cognitive Impairment, is confused/disoriented, has wandering behaviors and occasional inappropriate behavior such as taking other people's belongings. The physician's report does not indicate R1 has a motor impairment; however, resident's current/initial care plan, dated 8/5/22, notes resident needs escorts to activities, meals and toileting and staff assistance with using assertive devices, including a walker and/or wheelchair, and monitoring due to non-compliance. Additionally, LPA observed R1 to use a walker to help with ambulation when interviewing her on 1/19/23.

LPA interviewed resident (R1) on 1-19-23 and observed a larger sized Band-Aid to be on R1's left forearm. R1 stated to LPA that " the caregiver named Amelia tried to take a necklace from me and scratched me in the process", on 1-17-23. . R1 provided a physical description of how said caregiver wore her hair and dressed. R1 stated she noticed the cut on her wrist while on the bus, two days ago, and reported the cut to a nurse at the clinic who provided first aid care. R1 stated to LPA that she has fallen on two occasions before, stating "I fell in the dining room and slipped off my walker once before" and also "I slipped one time on the shower mat:. R1 indicated she does know a resident with the same first name as the staff person who allegedly grabbed her necklace from her neck.

All staff interviews confirmed there is currently not a staff person who goes by the first name, Amelia. Administrator stated she was not aware of the cut on R1's left forearm until she returned from the health clinic on 1/17/23, and then at that point, she completed and submitted a report to the Ombudsman. HSD stated R1 doesn't have any history of skin tears on her arms and the "story keeps changing" about the alleged staff member who tore the necklace off of her. One caregiver staff stated that R1 " gets clumsy every now and then and can lose her balance and is wobbly" when walking. A second caregiver staff stated R1 didn't mention anything to her about the skin tear and she could have bumped herself stating "when she had a skin tear before, she would "mess with it" and R1 "will always bring it to staff's attention when she has an issue". cont on 9099C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230118102646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CITRUS HEIGHTS TERRACE	FACILITY NUMBER: 347001498
	VISIT DATE: 02/23/2023

NARRATIVE

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9099C(2).. All staff interviews indicated that R1, and other residents, will enter other resident rooms and take things due to their cognitive diagnosis. Narrative charting notes for R1 document multiple instances of this behavior from September 2022- January 3, 2023.

LPA interviewed resident (R2) on 1-19-23. R2's Physician's Report, dated 5-28-22, notes R2 has a diagnosis of Dementia but is able to follow instructions and communicate her needs. R2 stated she knows R1 and sometimes they watch television together. R2 stated she never tried to grab a necklace off of R1's neck., stating she has never observed R1 to wear any necklaces. R2 added, "I do see some people going in other people's rooms sometimes" so she asked her family members to take her valuable jewelry home.

LPA contacted (2) individuals who work at R1's health care clinic. One of the individuals stated that she has only worked with R1 for a short time, but during that time, R1 mentioned an individual named "Amelia" on (3) occasions. Specifically, R1 stated that R1 was upset because Amelia "didn't put sugar on her rice". The same individual stated that she observed the scratch on R1's left forearm on 1-17-23 but does not have any information related to how it occurred.

LPA spoke to a second individual at R1's health care clinic who is a medical professional. LPA reviewed a copy of the nurse's notes from 1-17-23, which state that R1 reported that a caretaker from the facility "yanked her necklace off of her neck and accused her of stealing it" and "when the necklace was pulled off, the metal part of the charm cut into (R1's) left fore arm". Clinic notes show that wound care was provided and a photo was taken and forwarded to the clinic Nurse Practitioner (NP) as well as a follow up appointment scheduled for R1 for later that week. Additional notes state that per the opinion of the NP, the wound is not consistent with R1's reports but that the wound is consistent with a "bump" injury. NP stated that It looks to her as thought the participant bumped her left forearm on something and the skin tore.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning 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 left with Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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