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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:52:46 PM

Substantiated


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
09/23/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240923141420
FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:MAGDA LUISFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:49CENSUS: 47DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maga Luis, Interim Administrator TIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident being hospitalized.
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 complaint findings for a complaint received on September 23, 2024. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA spoke with Magda Luis, Interim Administrator, at the start and end of today's inspection.

During the investigation, the Department interviewed several facility staff members and reviewed documentation related to resident (R1), including 9-1-1 and hospital medical records. The results of the investigation as follows:

Documentation reviewed indicates resident (R1) requires four safety checks per shift, "ongoing assistance with care due to advanced Dementia, and has "poor safety awareness, poor judgment, disoriented to person/time/place and repeats information".

*cont on 9099C-1..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 5
Control Number 59-AS-20240923141420
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: 12/23/2024
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.. The fire department's report from 9/22/24 notes they were dispatched to the facility, at 1545 hours, for the reason "unknown problem/person down", arrived at 1551 hours and found (R1) "slouched in a wheelchair". The chief complaint noted on the report was "altered level of consciousness, possible heat stroke". Also documented is that facility staff reported there was a recent shift change and staff found (R1) who was left outside in the sun and with a blanket. Upon discovering (R1) outside, facility staff brought (R1) into the facility and called 9-1-1. Facility staff reported they believe (R1) may have been outside for a maximum of (3) hours and were not certain due to a recent shift change.

Hospital medical records indicate that (R1's) initial temperature was elevated and cooling protocols were implemented. A Computed Tomography (CT) was determined to be negative for intracranial hemorrhage or large brain mass.

Staff interviews indicated that (R1) was able to slowly ambulate themself in the wheelchair and would ask other residents for assistance, including to take them outside. One staff stated they believe (R1) asked another resident for assistance and that's how they got outside on the patio and staff didn't know where (R1) was. Shortly after shift change, (R1) was noticed outside on the patio but was not brought inside until about (40) minutes later, by the "pm" staff.

A second staff confirmed residents are allowed to go outside on the patio but staff try to re-direct residents from going outside, if it's a hot day. If staff are not able to redirect the resident, staff are to check on the resident who is outside every 10-15 minutes, offer water and keep trying to redirect the resident inside. This staff stated another staff informed them around 1530-1600 hours that (R1) was outside and needed to be checked on. This staff stated they observed (R1) to be wearing layers of clothing, was not responsive, their eyes were flickering and their skin was hot to the touch.

Neither the morning or afternoon staff assigned to care for (R1), or other staff, could confirm how long (R1) had been outside on the patio before being sent out for emergency services on 9/22/24, around 1530 hours, and being diagnosed with heat stroke. There is no camera coverage in the seating area where (R1) was.

*cont on 9099C-2...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240923141420
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/24/2024
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator conducted staff training on 9/24/24, with the "am" shift regarding checking on residents at least every hour and offering beverages to prevent dehydration. Documentation was reviewed showing staff provided 30 minute checks on (R1) the following day, on 9/23/24. New staff will receive training on outside monitoring of residents.
8
9
10
11
12
13
14
Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff frequently monitored resident (R1)'s condition while outside on the patio, on the afternoon of 9/22/24, to prevent (R1) from suffering a heat stroke, when temperatures reached 91*F, which posed an immediate health and safety risk to residents in care. Resident was sent to the emergency room at 1545 approximately and diagnosed with an altered state of consciousness and heat stroke.
8
9
10
11
12
13
14
The Administrator stated on 9/24/24 the camera monitor from her office will be moved to the front desk area and a bigger camera monitor will be installed in her office and in the dining rooms. Also staff will be asked to check residents outside, every 10 minutes.
*On 12/23/24, LPA observed the camera in the Administrator's office showed certain areas of the patio but not the seating area at this time.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240923141420
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: 12/23/2024
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.. Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

Exit interview with Resident Care Coordinator and Administrator (by phone). Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
09/23/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240923141420

FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:MAGDA LUISFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:49CENSUS: 47DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maga Luis, Interim Administrator TIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The above allegation was investigated by the LPA. The allegation states that resident (R1) was left outside on the patio one other time, for an extended perid of time, in June 2024, and became dehydrated and non-responsive but was not sent out for emergency medical services.

Resident (R1's) file was not readily available on 12/23/24 due to resident moving out of the care home, but the Department previously reviewed charting notes and did not note anything concerning for (R1) related to being left outside in June 2024. The Interim Administrator and Resident Care Coordinator and a staff member who provided regular care to (R1) indicated they are not aware of another incident when (R1) was left outside on the patio and suffered heat stroke. A second staff stated to LPA that (R1) most likely suffered a heat stroke on another occasion but would have been sent out to the emergency room. (R1's) family member was not able to be contacted for information.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 5