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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:55:13 PM

Document Has Been Signed on 10/21/2024 02:55 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR/
DIRECTOR:		MAGDA LUISFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 45CENSUS: 40DATE:
10/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Magda Luis, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Magda Luis, Administrator. LPA stated the reason for today's inspection relates to resident (R1) who had an unwitnessed fall on 8/28/24, in the morning, and was sent out for emergency medical services later that day. The facility submitted an incident report to the Department on 8/30/24.

The report for the emergency ambulance provider notes the facility contacted them on 8/28/24 (19:28 hours) for a fall, they arrived at the facility at 19:48 hours, and observed the resident to be resting in her bed. The report further states that resident had a fall earlier that morning (around 8:00 am), and had been sitting in a chair all day, as staff was unable to get resident to stand, contrary to resident's normal baseline of regularly walking around the facility. The report also states that facility staff reported to the ambulance provider they were told by morning staff that resident had a witnessed fall, did not hit her head, but were not given any additional details. Documentation reviewed shows resident arrived at the Emergency Room at 20:16, was diagnosed with a fractured left hip and remained hospitalized until 8/31/24 when she was discharged to skilled nursing for rehabilitation.

Several staff interviews were conducted, concluding resident (R1) had fallen and was found on the ground in the courtyard, on 8/28/24, after breakfast and before lunch was served, between approximately 10:00 - 11:00 hours. Staff interviews confirmed that after resident had fallen, (R1) was given assistance to stand up and was brought inside and seated in the dining room. Interviews revealed (R1) remained seated in the dining room until around 17:30 hours, when the facility nurse arrived to perform skin check on multiple residents. When the nurse observed (R1), she didn't want to stand up and complained of pain in her leg area. The nurse was advised resident fell earlier in the day and determined (R1) likely had a fractured hip, instructing that resident be sent out for a further medical evaluation.
**cont on 809C-1..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2024
NARRATIVE
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809C-1.. A "pm" staff stated he was made aware of resident experiencing pain around 17:00 hours, on 8/28/24, and stated if (R1) had been moving around during the "pm" shift, staff would have noticed her walking with difficulty.

Additionally, staff interviews provided conflicting accounts if resident ate her lunch and dinner on 8/28/24, while seated in the dining room.

The incident report (R1) notes resident around on 8/28/24, around 11:30 am-12:00 pm, and was sent out to the hospital for a possible injury. The family member reported to the facility that resident had a hip fracture and had surgery on 8/29/24.

Based on information obtained, the facility did not ensure resident received timely medical attention following her fall on the morning of 8/28/24, as the ambulance provider was not called until 19:28 hours.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency and civil penalty are being issued.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. 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: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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Document Has Been Signed on 10/21/2024 02:55 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 10/21/2024 at 01:57 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CITRUS HEIGHTS TERRACE
FACILITY NUMBER: 347001498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/22/2024
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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Licensee/Administrator agree to provide staff with training on fall protcols and when to send a resident out for medical attention.

Staff training to be completed and documentation provided to the Department by 11/4/24. Admin to advise LPA by 10/22/24 of the training agenda.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received timely medical attention, on 8/28/24, after having an unwitnessed fall that morning, as (R1) was not sent out to the hospital until 19:28 hours, and had displayed a change in baseline behavior with her mobility, which posed an immediate health and safety risk to residents in care. (R1) was diagnosed with a left hip fracture after being sent to the hospital on the evening of 8/28/24.
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An immediate civil penalty is being assessed today for $500.00.

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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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


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