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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:14:53 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
10/14/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20241014152140
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:
01/31/2025
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Ashley Stahl, Resident Care Coordinator TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff do not provide adequate laundry services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to (4) additional allegations of a complaint received on 10/14/24. LPA met with Ashley Stahl, Resident Care Coordinator, and stated the reason for today's inspection. LPA was advised that the Interim Administrator, Magda Luis, was currently out of the building.

During the investigation, LPA interviewed the Administrator, Maintenance Director, (3) staff, and a resident's family member. LPA observed the laundry room on 10/21/24, on 1/29/25. The results of the invesitigation are as follows:

The allegation states that laundry is not getting completed and delivered back to residents' rooms timely, due to not having enough staff to assist with laundry.

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

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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 6
Control Number 59-AS-20241014152140
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: 01/31/2025
NARRATIVE
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9099C-1.. The Administrator stated the "am shift does laundry and the "pm" shift puts the laundry back". confirmed that the NOC shift washes "linens only", and housekeepers will "help start the laundry". The Administrator added that it's "challenging when clothing is not labeled" and confirmed that "laundry is included" in the basic services the facility provides. The Administrator explained that on 10/10/24 the dryer company came out and cleaned all ducts and machines and soon afterwards, one of the dryers did not work properly. The Administrator confirmed that staff has "not used the dryer since Friday", 10/18/24 and that maintenance staff called the repair company on Friday, 10/18/24, to request they fix it. The Maintenance Director confirmed, on 10/21/24, the facility dryer is not currently working, the repair was called in on 10/18/24, and on 10/22/24 or 10/23/24, the repair company would come out and repair the machine.

One staff stated that laundry "can pile up" and explained how she recently "found a pile of dirty clothes that were left on the shower bench in a resident bathroom". This staff stated she is not sure if it was a hospice staff or a facility staff that left the laundry in the bathroom, but she took the laundry to the laundry room to be washed. This staff indicated that "all shifts do laundry" and the person who starts the load may not be the person who finishes the load, adding there is a "lot of laundry done" but was not sure if it is being completed timely.

A second staff stated she is "not sure if there is a time" when it's not done timely, asserting "the "am" shift is much busier- we have no down time", explaining all caregivers assist with laundry and when they go in the laundry room, they "rotate the clothing between the washer and dryer" to ensure it keeps moving through the laundry cycles. This staff stated "laundry will be rotating throughout the day" and "we (staff) try to maintain laundry going in and out, on both the "am" and "pm" shifts, in between showers". This staff added the "pm" shift has "down time" and caregivers will go back regularly to check on the laundry to ensure it's being completed, commenting, "everyone is accountable for getting laundry going".

A third staff confirmed there was a dryer issue a few months ago, in October 2024, relating to the bottom dryer "overheating", adding the top dryer has also had issues. This staff stated that staff are told to "go back and check on laundry during their downtime" and that she "tries to do all the linens first so there are towels for showers". This staff indicated that residents often wear clothes that don't belong to them, and she has seen residents wearing two different shoes before. This staff added "most resident's don't have pajama set so they wear a pajamas top and brief", and "socks seem to be a problem as there are (2) boxes now that are clean and not delivered". LPA observed (1) box of clean socks in the laundry room on 1/29/25 in the afternoon . *cont on 9099C-2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20241014152140
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: 01/31/2025
NARRATIVE
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9099C-2.. A family member stated that the laundry has not been processed timely for months and clothing and linens are not being returned to the correct resident, explaining they have observed many residents wearing "mismatched and ill fitting clothing" and shoes that also don't match. Currently, this family member's resident is missing a pair of pajamas, their roommate is using their bottom sheet, and staff are putting their roommate to bed wearing jeans instead of pajamas.

On 10/21/24, LPA observed one dryer to have a sign posted that it was not working as of 10/18/24. On 1/29/25, LPA observed both dryers to be working in the laundry room and residents in the dining rooms to be wearing correctly matched shoes when they were eating lunch around 12:30 pm.

Interviews with staff and a family indicated there are regular issues with one of the dryers working correctly, "there are not enough people to keep the laundry going" and it would be helpful to have one designated staff overseeing the laundry processes to ensure laundry is being washed and returned timely and correctly to each resident.

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.

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 Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 59-AS-20241014152140
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: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/14/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Resident Care Coordinator and Administrator are working on creating a new laundry schedule for each resident in the building, based on where their room is located. Training to be conducted to explain the new procedures- to be submitted to the Department by email/fax by 2/14/25.
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Based on interviews conducted and observations made, the Licensee did not ensure that laundry services meet each resident's needs, including sufficient and trained staff to complete the laundry processes, and delivering clean laundry timely to each resident, which poses a potential personal rights violation to residents in care.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/14/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20241014152140

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: DATE:
01/31/2025
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff are not adequately trained.
Staff yell at residents.
Staff are not meeting residents' showering needs.
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed the Administrator, (3) staff, and a resident's family member. LPA also reviewed staffing records for newer staff and shower records for the month of October 2024. The results of the investigation are as follows:

Allegation: Staff are not adequately trained. The allegation states that staff are hired and not provided with training.

The Administrator stated that it takes new staff 3-4 days to complete in-person/computer training and another 3-4 days shadowing experienced staff. LPA reviewed training records for (6) newer staff who began working at the facility within the last (6) months. All training records reflect that each staff had completed the required initial training hours and topics. Shadowing hours were not reviewed at this time.

Based on information obtained, LPA finds this allegation 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. *cont on 9099A-C-1...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20241014152140
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: 01/31/2025
NARRATIVE
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9099A(C)-1... Allegation: Staff yell at residents. There was no additional information provided.
The Administrator stated "sometimes caregivers speak loudly due to hearing issues with residents or because staff is so excited to see the residents" and commented "many residents have hearing loss and it's more staff's tone than their volume". The Administrator clarified, "I hear louder voices but not yelling".

One staff stated she does not recall staff yelling, "but yes, staff can talk loudly if there are hearing issues with the residents or be more firm and raise their voice to redirect a resident's behavior". This staff gave the example of a resident being aggressive with another resident and a staff needing to raise their voice to redirect the resident. A second staff stated that staff do "not yell purposely" but staff do raise their voice so a resident can hear and confirmed that both caregiver and Med-Tech staff sometimes raise their voices. A family member stated she has not heard any staff yell at residents and staff are "really sweet and very nice".

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.

Allegation: Staff are not meeting residents' showering needs. The allegation states residents are not being showered as scheduled.

The Administrator stated staff will record when the residents refuse a shower and the documentation is kept for a month. A family member stated she was told she could check the shower roster if she has concerns her family member is not being bathed. Two staff stated showers are given throughout the day, on the "am" and "pm" shifts and showers are scheduled twice weekly, or as needed.

LPA reviewed approximately (40) resident shower schedules for the month of October 2024, from 10/1/24 through 10/21/24. LPA observed schedules to be consistently initialed by facility staff as completed or refused by resident. Most schedules showed residents were receiving a shower for an average of two times per week and some schedules noted when hospice staff gave the shower.

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: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6