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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 11/18/2025
Date Signed: 11/18/2025 01:53:31 PM

Substantiated


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
08/18/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250818132224
FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:VERONICA MORALESFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:49CENSUS: 37DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Magda Luis, Administraor TIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff do not provide adequate care and supervision to the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on August 18, 2025 and met with Interim Administrator, Magda Luis, and stated the reason for the inspection. Also present was Resident Care Coordinator, Rachael Robert.

During the investigation, LPA interviewed multiple facility staff, including the Administrator at the time, Interim Resident Care Coordinator, (1) Med-Tech, and (1) family member of resident (R1). (R1) was not able to be interviewed due to their diagnosis of Dementia and limited verbal ability. Additional staff who had knowledge of the incident were not available for an interview. LPA reviewed documentation related to (R1) including, but not limited to, the Physician’s Report, Assessment, Service Plan, Charting Notes, Incident report (LIC624) and Medication Administration Record (MAR) for August 2025. The results of the investigation are as follows:

*cont on 9099C-1..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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 5
Control Number 59-AS-20250818132224
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: 11/18/2025
NARRATIVE
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9099C-1.. Allegation: Staff do not provide adequate care and supervision to the residents.
The allegation states that on Tuesday (08/05/2025) around dinner time, resident (R1) was escorted to the dining table but managed to wander out of the dining room and into the hall, where (R1) fell and broke their nose in two places, requiring stitches on their lips.

The family member stated in August 2025 they are concerned that the residents at the facility aren't getting proper supervision, and staff are not "hands-on enough" to prevent things like this from happening. This family member stated they also have had to lend a hand for (R1) and for other residents when visiting.

Two (2) staff interviews conducted on August 19, 2025 revealed that (R1) was running in the hallway earlier in the day on August 5,2025, around 11:00 am, which was unusual behavior for (R1), and this was the first time (R1) was observed to run. The re-assessment (dated July 21, 2025) notes (R1) "will walk around the community very slowly". The administrator explained, on August 19, 2025, that a third staff, who "was not assigned to care for (R1)" let a Med-Tech (S1), working on the "am" shift, know that (R1) was "acting very off" that day, and explained how (R1) was "leaning forward when walking and was very agitated". The administrator indicated that (R1) was "not listening" to staff earlier that day before falling around 4:45 pm.

(R1's) re-assessment (July 21, 2025) notes “Staff will observe resident expressions due to UTI’s, will tend to peri care area for cleanliness and report any changes”. The assessment also notes (R1) needs Full assistance with feeding and mealtime support- Staff need to pay attention as some days may need extra help/cueing. The reappraisal also states that (R1) needs "maximum assistance with ongoing strategies to maintain safe and appropriate interactions" and for staff to "provide enhanced interventions and care coordination to de-escalate negative behaviors".

The incident report (LIC624) submitted to the Department on August 6, 2025 describes the conditions leading up to (R1) experiencing a fall face down in the hallway on August 5, 2025 (4:45 pm). The LIC624 notes that prior to the fall, (R1) was "observed to be walking at a fast paced around the hallway" and that "care staff approached (R1), but (R1) declined assistance". The report also states that "later during the dining period, the resident was in and out of the north dining room when (R1) accidentally bumped into the door frame of resident room (#), causing (R1) to lose balance and fall face first on the carpeted floor". (R1) sustained a nasal laceration and nasal bone fracture and returned with stitches on their nose".

*cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250818132224
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: 11/18/2025
NARRATIVE
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9099C-2.. Charting notes entered by a Med-Tech staff (S2) who witnessed the fall document that "Resident was seen walking fast paced around the facility- multiple care staff and both Med-Techs tried to get (R1) to have a seat but (R1) got agitated and refused assistance. (R1) walked in and out of north dining room, bumped into the door frame (nearby room), lost balance and fell face first into the carpet".

Charting notes entered by the Interim Resident Care Coordinator on August 7, 2025, describe how "prior to the incident, (R1) was observed to be walking at a fast pace around the hallway"; care staff approached (R1) to suggest a seat, but (R1) declined assistance". The notes describe (R1's) agitation just prior to the fall and how (R1) was "in and out of the north dining room when accidentally bumped into the door frame" of a nearby room. The notes also state (R1's) family member was present to take a photo and video of (R1) when the ambulance provider arrived.

The administrator stated staff observed a "lot of blood" after (R1) fell, and (R1's) "whole eye area and cheek area were purple", confirming (R1) returned later that day around 9:00 pm with a Urinary Tract Infection (UTI) and 5-day antibiotic". The MAR shows that Amoxicillin 875-125 mg was prescribed to start on August 6, 2025, one tablet every (12) hours for (5) days, until August 10, 2025 and Naproxen 500 mg was prescribed to be given twice per day, on August 7, 2025, as needed for mild pain for (14) days. Additionally, the MAR reflects Aspirin 81 mg was held from August 6, 2025 through August 11, 2025.

The Administrator stated on August 19, 2025 that maintenance staff, tried to access the video footage from 8/5/25 (4:45 pm) but was not able to and commented that the video "may not be available after a week". LPA spoke to maintenance staff on this same day who confirmed he was unable to access the video.

(R1's) family member stated they will "hold (R1's) hand as (R1) can't see that well" and confirmed they visit (R1) regularly. The physician's report notes (R1) has a visual impairment and does not like to wear their glasses. The care plan notes (R1) needs full assistance with vision care, staff are to assist as individuals living with Dementia may not see from the sides, resident refuses to wear glasses and (R1) "needs to be escorted to meals, hand held and guided". Although the allegation states (R1) was escorted to the dining room prior to the fall on August 5, 2025 (4:45 pm), charting notes made by (2) different staff indicate that (R1) "was in and out of the north dining room, and accidentally bumped into the door frame, causing her to lose balance and fall face first".

*cont on 9099C-3.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250818132224
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2025
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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The Licensee/Administrator agree to conduct in-service training with all staff to discuss following protocols when there is change of condition, including contacting the resident's primary care provider for direction, requesting a UTI analysis.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff provided the necessary interventions on August 5, 2025, starting at around 11:00 am, when (R1) was observed to be running throughout the facility, until 4:45 pm, when (R1) fell near the dining room and sustained a nasal bone fracture and laceration on the nose and lips,, requiring stitches in the emergency room, which posed an immediate health and safety risk to residents in care.
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Training agenda/date due by tomorrow, November 19, 2025- additional time can be allowed for the training itself (2 weeks).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250818132224
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: 11/18/2025
NARRATIVE
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9099C-3..Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.

Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5