347001498-1-15-2025-59-AS-KHOS-DD5HNF-20250121052037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:57:14 PM

Unsubstantiated

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
07/01/2024 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240701085917

FACILITY NAME:	CITRUS HEIGHTS TERRACE		FACILITY NUMBER:	347001498
ADMINISTRATOR:	TONI JONES		FACILITY TYPE:	740
ADDRESS:	7952 OLD AUBURN ROAD		TELEPHONE:	(916) 727-4400
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	49	CENSUS: 49	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Magda Luis, Interim Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility Staff's Neglect/Lack of Care and Supervision resulted in resident sustaining an unexplained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings for a complaint received on July 1, 2024. LPA met with Magda Luis, Interim Administrator, and stated the reason for today's inspection.

During the investigation, the Department interviewed several facility staff members, hospital staff, and reviewed documentation related to resident (R1), including, but not limited to, 9-1-1 and hospital medical records. (R1) moved to the facility on/around January 2024. The results of the investigation as follows:

On 6/28/24, at 1000 hours approximately, resident (R1) was complaining of pain in their breast, ribs, neck and knee areas. (R1) was transported to a nearby medical center on the same day and diagnosed with a "cervical vertebral fracture, a right single rib fracture, and a right chest wall contusion".

*cont on 9099C-1...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 3

Control Number 59-AS-20240701085917

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: 01/15/2025

NARRATIVE

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*9099C-1...Facility staff were interviewed and unable to explain how (R1) sustained these injuries and residents were not able to provide any information on (R1's) injuries or the incident on 6/28/24. (R1) was attempted to be interviewed, but they were not able to provide any information on the incident or how they sustained the injuries.

The emergency room physician who attended to (R1) on 6/28/24 explained that a typical way an individual could sustain a neck injury would be if he/she fell face down or ran into a wall, causing the individual's head to be pushed back. This same physician noted that it wouldn't be unusual for an individual to go to the emergency room complaining of neck pain and discover they had a neck fracture.

The physician confirmed that based on (R1's) medical records from November 2023, (R1) did not have a documented neck fracture, so it's reasonable to believe the neck fracture occurred between November 2023 and June 2024. Additionally, the physician confirmed that the neck fracture did not appear to be new in June 2024 and appeared to be approximately four to eight weeks old, if not older. The physician further indicated that he could not imagine a C2 (neck) injury happening to (R1) since they were bed-bound or wheel-chair-bound; however it would not be unexpected, and there would have had to have been some kind of force. Also, if (R1) had fallen, there would likely have been facial bruising, which was not observed on (R1) when going to the Emergency Room on 6/28/24.

Finally, the physician confirmed that (R1) did have a previous fall, in February 2024, and indicated that it's possible this previous fall could have been related to the C2 fracture, but it could not be confirmed without knowing the circumstances of the fall in February.

Medical transport records from 6/28/24 note that one staff was not aware of (R1) complaining of neck pain, but was concerned about them having a hematoma, or bruising to the right chest wall. Records state that this facility staff first noticed the bruising earlier that morning when assisting (R1) with dressing, and there was no injury or trauma noted to have caused the hematoma. One facility staff stated she was off work on 6/28/24 and was not aware of any bruising (R1) had.

A second staff could not recall if he was not assigned to work, or work with (R1), on 6/27/24. This staff stated (R1) spent most of their time in bed, needed assistance with feeding and transfers, and would be "combative" with staff when staff tried to change them. This staff also reported that (R1) was not a fall risk as *cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240701085917

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: 01/15/2025

NARRATIVE

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9099C-2... they would not try and get out of bed unless staff was there to assist, and it was rumored that (R1) may have been "mishandled" by staff during a transfer; however, this was staff talking in the break room.

A third facility staff indicated that she recalls when (R1) was found in bed with a bruise on their side, around 6/28/24, but did not know how the bruising was sustained. This staff indicated that staff were not talking about or seemed to know how the bruising occurred, which she found strange. This staff stated that the bruising could have possibly happened on the night shift, as she did not observe any bruising on the morning of 6/26/24 or 6/27/24, and added that (R1) was not a resident who would try and get out of bed on their own. This staff added that she has never seen a facility staff being aggressive with (R1) or (R1) to be aggressive with another resident.

A fourth facility staff indicated that she was first made aware of bruising on (R1) from an "agency staff" on the morning of 6/28/24, when she was called to (R1's) room, and observed she had already been transferred to their wheelchair. The facility staff indicated she asked facility staff who had worked the prior afternoon about the bruising, and no staff could provide any information on how (R1) sustained their injuries. This facility staff stated she was not able to communicate with any staff who worked on the night shift from 6/27/24 -6/28/24, and also could not confirm which staff actually worked as the schedule may have changed and an "agency staff" could have filled in.

On 7/4/24, (R1) was discharged to a skilled nursing facility with orders to wear an Aspen collar for three months. (R1) did not return to the facility following her stay in skilled nursing.

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.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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