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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003712
Report Date: 07/02/2021
Date Signed: 07/02/2021 03:17:40 PM

Document Has Been Signed on 07/02/2021 03:17 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BROOKDALE CITRUS HEIGHTSFACILITY NUMBER:
347003712
ADMINISTRATOR:ALEJANDRA C SALLEEFACILITY TYPE:
740
ADDRESS:7375 STOCK RANCH RDTELEPHONE:
(916) 729-2722
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 56CENSUS: 19DATE:
07/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Christine Sallee, Executive DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 7/2/2021 LPA Todd Tryon arrived at the facility to conduct a case management visit. LPA met with ED Christine Sallee.
Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs were screened by facility staff upon entering the facility.
The purpose of this visit was to discuss Incident Reports submitted for 5/12/2021 and 5/19/2021. Through review of reports and interview with staff, LPA found the following:
On 5/12/2021 it was reported that resident R1 received the wrong medication. R1 received Lorazepam 0.5 mg instead of Alprozolam 0.5 mg. This situation was corrected noted, resident was monitored and showed no adverse reactions.
On 5/19/21 staff found that an order for resident R2 was entered incorrectly on the electronic Medication Administration Record (MAR). Order was for Amlodipine 10 mg; but had been entered as Amlodipine 20 mg; therefore resident had received the wrong dosage. MAR was corrected, resident was monitored and showed no adverse reactions.
As per review of Incident Reports and interview with ED, staff have received additional training regarding Medication Management.
The following deficiencies are being cited as per Title 22 Regulations. Appeal rights were proviced, exit interview conducted.
This is the second time this particular regulation has been cited in the past 12 months. Therefore, a Civil Penalty is issued.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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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Document Has Been Signed on 07/02/2021 03:17 PM - It Cannot Be Edited


Created By: Todd Tryon On 07/02/2021 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BROOKDALE CITRUS HEIGHTS
FACILITY NUMBER: 347003712

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2021
Section Cited
CCR
87465(a)(5)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The licensee will ensure that residents are assisted with self-administered medications as needed; and that residents receive the correct medications in the correct dosages.
The facility has been doing on-going addtional medication training with staff since the incidents were discovred. Administrtor will
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Through review of records and interview, LPA learned that R1 received the wrong medication on 5/12/21; and on 5/19/21 it was found that medication for R2 was entered into the electronic MAR in the wrong dose, causing R2 to receive the incorrect dosage of medication.
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submit proof of medication trainings for relevant staff to CCL by POC due date of 7/6/2021.

Since this is the third time this regulation has been cited in a 12-month period, a civil penalty is being issued.

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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.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021


LIC809 (FAS) - (06/04)
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