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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920099
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:44:55 AM

Unfounded


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
07/05/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20240705090948
FACILITY NAME:SPRING AZURE SENIOR CAREFACILITY NUMBER:
345920099
ADMINISTRATOR:CHUA-HARRIS, CHRISTINE DYAFACILITY TYPE:
740
ADDRESS:6924 OAK SPRING WAYTELEPHONE:
(916) 579-9222
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Dyan Christine Chua-HarrisTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff are using a medical device on resident without authorization.
INVESTIGATION FINDINGS:
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On 09/26/24, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to deliver final findings Community Care Licensing (CCL) received on 07/05/24. LPA met with Administrator, Dyan Christine Chua-Harris and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 2
Control Number 59-AS-20240705090948
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: SPRING AZURE SENIOR CARE
FACILITY NUMBER: 345920099
VISIT DATE: 09/26/2024
NARRATIVE
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Allegation- Staff are using a medical device on resident without authorization. - UNFOUNDED

The Department conducted record review and interviews with staff and residents to investigate this allegation. It was alleged that facility is using an external catheter for resident, R1 without physician’s order for R1’s toileting care needs. Record review indicated that per R1s physician, facility does not require any doctor’s order to use external catheter to address resident’s toileting care needs as it falls under Incontinent Supplies which does not require any doctor’s orders. During staff and resident’s interview, it has been concluded that facility tried to use external catheter for a day, but it did not work out, so staff stopped use. R1 did not verbalize any issues with external catheter and were at their baseline without any issues. Based on gathered information, it has been concluded that facility used external catheter to address R1s toileting needs but that was not a violation of Title 22 Regulations, therefore, this allegation was found to be UNFOUNDED.

 Exit interview conducted. A copy of the report and appeal rights left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2