347001498-11-7-2025-59-AS-MSEY-DNAVT7-20251110154239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 11/07/2025
Date Signed: 11/07/2025 02:51:52 PM

Unsubstantiated

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
09/30/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250930083209

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	VERONICA MORALES		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	49	CENSUS: 35	DATE:	11/07/2025
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Veronica Morales, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide adequate supervision, resulting in resident sustaining bruises.
Staff do not ensure that resident is hydrated.
Staff do not maintain facility free from odor.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on September 30, 2025 and met with Editha McCullough, Resident Care Coordinator, and stated the reason for the inspection. Administrator, Veronica Morales, Administrator, returned from lunch shortly.

During the investigation, LPA interviewed multiple facility staff, including the Administrator, Med-Techs, Caregivers, a Housekeeper, a Psychiatric and Mental Health Nurse Practitioner, and (2) family members of (R1). LPA reviewed documentation related to (R1) including, but not limited to, the Physician’s Report, Assessment/Service Plans, Charting Notes, Mental Health notes and (2) communications to the facility, Medication Administration Records (MAR), and (2) photos provided to the Department. The results of the investigation are as follows:

*cont on 9099C-1..

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

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 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099C-1.. Resident (R1) moved to the community on April 19, 2021 with a primary diagnosis of Dementia and a secondary diagnosis of hypertension, anxiety and depression. (R1) remained ambulatory during their entire stay through October 21,2025 and needed moderate assistance with bathing, dressing, and grooming. The care plan (6/17/2025) additionally notes that (R1) needed maximum assistance with toileting, cognitive tasks such as orientation and redirection, and with staff interventions and care coordination to de-escalate negative behaviors.

Allegation: Staff did not provide adequate supervision, resulting in resident sustaining bruises. The allegation states that staff did not provide adequate supervision, resulting in (R1) sustaining bruises on their arms.

The assessment (6/17/2025) notes that (R1) is independent and doesn’t need any assistance due to not presenting a risk of wandering/elopement but does need moderate ongoing support for disruptive sleep patterns. A family member stated that neither staff nor (R1) are able to state how the bruises occurred. The Administrator stated she was not aware of any bruises and never saw them. When showed the photo, the small circles appeared to be at different stages of healing. The administrator stated (R1) talked to themself a lot and could have bumped into things in their room. Additionally, they could be a side effect of the medication.

On October 2, 2025, a caregiver stated (R1) has "spots on both arms and has had bruises for at least a month", commenting she sees them when (R1) reaches for a cup but didn’t know how the bruises occurred but can "see the decline in (R1’s) face". This care staff stated she has never seen (R1) get physically aggressive with anyone and is "really outgoing with residents, giving them a "high fives", verbally, or fist bumps"; however, (R1) will bump into things in their room. A second caregiver indicated she "does not know about any bruises as (R1) won't let staff shower them, and (R1) has "refused the medication for showers to calm them".

The photos provided to the department showed three small bruises on each fore-arm. The family members stated they think the bruising aligns with fingers. The resident's charting notes reviewed from August 2025 through September 3, 2025 did not document any bruising on (R1's) arms. With showers not being permitted by (R1), staff was not able to do any skin checks.

Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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.

*cont on 9099C-2.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099C-2.. Allegation: Staff do not ensure that resident is hydrated. The allegation states staff may not be hydrating (R1) because when visiting (R1) for two hours, staff did not offer resident water, they did not have a water bottle in their room and their urine smelled strong.

The care plan (dated 6/17/2025) indicates that moderate assistance is needed from staff with (R1's) eating and drinking, including encouraging hydration. An subsequent assessment (dated 7/25/2025) notes that (R1) needs encouragement with hydration.

A housekeeper stated (R1) always fills up their 49'ers cup and has 2-3 cups total and thinks (R1) "drinks enough". A Med-Tech staff stated "(R1) always gets juice in the dining room and always has 2 cups to fill". This staff stated she hasn't seen the 49er cup and hasn't seen (R1) get water but confirmed that staff "regularly offer water to other residents but residents prefer juice". The administrator showed LPA where the juice dispenser is located in each dining room and stated the "punch" is sugar free and only lightly flavors the water so residents will drink it more. The administrator stated (R1's) family member provided a second 49er cup following the meeting on October 10, 2025, and she observed (R1) to be drinking from it.

Another caregiver confirmed (R1) can get water without assistance from staff and he is "very good at getting the juice/punch that is available in the dining room". This staff commented that (R1) "eats a lot and does not refuse meals" and confirmed that staff offer liquids to residents in both dining rooms and there is also a dispenser with flavored water which residents know as "punch".

A second caregiver stated she will offer water with the medications, and residents are offered water in the dining room. This staff confirmed (R1) will also ask for water and can fill up water by themselves as they are totally ambulatory. This staff indicated that during meals and activities, staff will offer hydration to residents, and there is a punch cart.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099C-3.. Allegation: Staff do not maintain facility free from odor. The allegation states (R1’s) room smells really bad.

Both the care plan and assessment indicate that (R1) needs full assistance with all aspects of bathroom activities and hygiene, and staff need to monitor and check on (R1) periodically to confirm that “toileting has gone successful”.

LPA and a Licensing Program Manager observed a strong odor to be in the hallway area near (R1’s) closed door on September 18, 2025. LPA observed a pervasive odor again coming from/near (R1’s) open door on October 15, 2025. LPA did not observe incontinent odors to be present in other areas of the facility during this inspection or subsequent ones.

Both the family member and administrator stated that the family had an air purifier delivered to the facility. The administrator stated the purifier was on and working, but it didn't make a significant difference in the odor in the room.

Staff interviews indicated that overall housekeeping does an effective job in maintaining odor control throughout the building.

A housekeeper confirmed the caregivers will change resident's sheets and clean the bathroom as there is "urine in the floor", and commented that (R1) "peed one time in the shower" and she has not tried to open the window, as (R1) won't allow it "even for a little fresh air".

Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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 provided.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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
09/30/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250930083209

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	VERONICA MORALES		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	49	CENSUS: 35	DATE:	11/07/2025
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Veronica Morales, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are threatening to unlawfully evict resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

During the investigation, LPA interviewed multiple facility staff, including the Administrator, Med-Techs, Caregivers, a Housekeeper, a Psychiatric and Mental Health Nurse Practitioner, and (2) family members of (R1). LPA reviewed documentation related to (R1) including, but not limited to, the Physician’s Report, Assessment/Service Plan, Charting Notes, Mental Health notes and (2) communications to the facility, Medication Administration Records (MAR), and (2) photos provided to the Department. The results of the investigation are as follows:

Allegation: Staff are threatening to unlawfully evict resident. The allegation made on September 30, 2025 states staff are threatening to unlawfully evict resident (R1) due to the resident refusing to shower and that staff agreed they would try new medication to see if that would help with compliance. The allegation also states that (R1) has not been on the new medication long enough for staff to see a change, however they are still moving forward with the eviction.
*cont on 9099A-C-1..

Unfounded

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

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

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099A-C-1.. The administrator stated to LPA and a Licensing Program Manager (LPM) on September 18, 2025 that she and staff have "tried everything", including telling (R1), "let's shower and get pizza before the 49'ers game starts", and (R1) will "slam doors" and scream. The administrator stated she has talked with (R1’s) newly assigned psychiatrist who wants to change (R1’s) medications but doesn't want (R1) to be lethargic. During this meeting, it was also discussed how issuing a (30)-day eviction notice may be the appropriate step to take as (R1) has refused to take a shower, or allow staff to help provide essential hygiene care, or change their clothes.

The administrator confirmed (R1’s) care plan was updated in July 2025 to reflect (R1’s) continual refusal of showers. On August 1,2025, a virtual meeting was held with (R1’s) mental health provider, (R1), their family and the facility due to (R1) continuing to refuse showers, having soiled bedding, and becoming agitated when prompted by staff and poor hygiene; however, (R1) remains compliant with taking medications. Plan includes “initiating Memantine and Brexplprazole, discontinuing Buspirone and gradually tapering Lorazepam next visit”.

(R1’s) family member stated that there was a virtual meeting held on August 28, 2025 with (R1’s) psychiatrist at the time and it was discussed how (R1) continues to refuse to take showers on a regular/daily basis, and that the psychiatrist said to change (R1’s) meds and see how (R1) does.

The administrator confirmed the purpose of the meeting was to discuss (R1) continuing to refuse showers, and the doctor dropping (R1) who was changed to a local doctor through a different health care provider on August 30, 205. The mental health meeting notes document the reason for the meeting was due to (R1) “experiencing behavioral issues such as aggression and lack of compliance with hygiene” and that (R1) had not showered in over a month and remains combative with hygiene care”. The notes state that Rexulti 2mg was recently started, with minimal behavioral change and PRN Lorazepam 1 mg #8/month was added for acute agitation prior to giving a shower; (2x/week) Memantine was increased to 10 mg; continue Donepezil; support hygiene compliance, staff to monitor/report consistently.

The administrator stated she discussed the family participating through FaceTime in encouraging (R1) to take a shower, but the family felt it was solely the facility’s job to encourage (R1) to do so.

*cont on 9090A-C-2..

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099A-C-2.. The department reviewed a letter, dated August 29, 2025, sent from the psychiatrist to the facility regarding their communications the prior day of “resident’s refusal of showering and clothing changes, and subsequent agitation with staff. Please proceed with administration of PRN medication as clinically appropriate to help calm the patient”. Also decided during the meeting was that (R1) will “transition to a different psychiatric provider who will be able to see the patient in person and provide a more appropriate level of care needed’.

LPA reviewed a letter, dated September 25, 2025, sent from (R1’s) current Psychiatric and Mental health Nurse Practitioner to the facility. The letter states it was written to provide a “psychiatric evaluation of (R1) who is currently facing potential eviction due to hygiene -related concerns”. The letter documents that (R1) has not reportedly engaged in bathing or showering for the past two months; however, the resident indicated they have been showering when asked. This medical professional expressed that it is her “clinical opinion that (R1) is presently incapacitated in self-care, specifically regarding personal hygiene”, and there have been several conversations with (R1’s) responsible person on their “disease progression and manifestations, their cognitive capabilities and goals of care and treatment”.

The MAR reflects these multiple medication changes. The facility charting notes from June 2025- September 2025 document multiple times when (R1) refused showers or to change their clothes when staff offered to assist and was screaming and slamming doors. The notes also document that multiple attempts were made by staff, at different times of the day, on many days and (R1) still refused.

Staff interviews conducted on October 2, 2025, indicated that (R1) will refuse a shower saying they already took one or would take one “tomorrow”. Interviews also concluded that (R1) has shown a decline in condition over the last few months, since around June/July 2025. A Med-Tech staff stated she has seen a decline with (R1) and they have "refused increasingly more over the last 3 or 4 months" and will "slam the door and yell at staff".

A housekeeping staff stated (R1) will allow her to enter their room to clean it, and she will ask (R1) "daily about taking a shower and they always tell me they will tomorrow". This staff stated (R1) can be aggressive and thinks staff have tried everything to get them to shower.

Additionally, the administrator confirmed that (R1) would not use moist towels provided by the facility or the wipes the family brought in.

*cont on 9099A-C-3..

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 59-AS-20250930083209

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: 11/07/2025

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
26
27
28
29
30
31
32

9099A-C-4.. All staff stated that (R1) will willingly take their medications, on a daily basis, except for the Lorazepam pill to help calm them prior to offering/giving a shower.

LPA reviewed documentation written by the facility's Regional Nurse, Allison Lopez, LVN, on September 29, 2025 following her appraisal of (R1) that day. The documentation states that "(R1) requires assistance with dressing, incontinence care and showers but continues to refuse this assistance from staff. (R1) will yell, scream and slam their door when offered assistance, despite the need". The documentation additionally reads that due to the facility being "unable to provide necessary assistance with ADL needs, we have determined that we are unable to meet (R1's) care needs" at the facility and "(R1) is no longer appropriate for residency at the facility and requires a level of care beyond what the the facility can provide".

The administrator stated on October 2, 2025 that the facility had not issued an eviction notice and confirmed that to still be the case on a subsequent inspection on October 15 and November 4, 2025.

On October 10, 2025, a care conference meeting was held at the facility with the administrator, (R1's) family members and the Regional Nurse. The pending eviction was discussed due to (R1) continuing to not allow staff to provide essential care, specifically with showers and changing clothing. When the family went to tell (R1) that would happen, (R1) threatened to hit one of the family members.

One family member indicated that a notice had not been received as of October 2, 2025, and the second family confirmed that a notice had not yet been issued as of November 4, 2025. The administrator indicated that (R1) moved from the facility on October 21, 2025, and a notice was never issued.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC9099 (FAS) - (06/04)

Page: 8 of 8