<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:44:38 AM


Document Has Been Signed on 04/21/2023 11:44 AM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:TINA PREWITTFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:45CENSUS: 44DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tina Prewitt, Administrator TIME COMPLETED:
11:25 AM
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 case management inspection related to an incident that occurred on 4/15/23 between residents (R1 and R2). LPA received an incident report dated 4/17/23 for the incident.

LPA attempted to speak to resident (R1) in the presence of Administrator, but resident was not able to be understood but was in a pleasant mood. LPA did not observe R1 to show any bruises on her face or lower legs that were not covered by clothing. R1 was sitting in a wheelchair next to one of the glass exit doors, enjoying the outside view and/or sun. LPA observed R1 able to move herself in a wheelchair and Administrator confirmed that R1 is able to self ambulate in her wheelchair.

Administrator stated that resident (R2) who was involved in the incident was taken to the emergency room for a mental evaluation on 4/15/23 and will not be returning to the facility due to changes in behavior from a recent stroke.

Administrator confirmed that the Ombudsman's office was at the facility earlier this week also to follow up on the incident reported.

There are no deficiencies issued on this report.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1