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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001498
Report Date: 08/04/2025
Date Signed: 08/04/2025 02:56:22 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
04/08/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250408122042
FACILITY NAME:CITRUS HEIGHTS TERRACEFACILITY NUMBER:
347001498
ADMINISTRATOR:VERONICA MORALESFACILITY TYPE:
740
ADDRESS:7952 OLD AUBURN ROADTELEPHONE:
(916) 727-4400
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:49CENSUS: 43DATE:
08/04/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Veronica Morales, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff failed to provide adquate supervision which resulted in one resident assaulting another resident, who required hospitalization and surgery.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on April 8, 2025 and met with Veronica Morales, Administrator, stating the reason for the inspection. The facility is licensed for (49) residents, all of whom have a diagnosis of Dementia.

During the investigation, the Department conducted interviews with multiple facility staff, residents, hospital personnel, and reviewed multiple pages of documentation for both residents (R1) and (R2), including facility documents and hospital documents. The results of the investigation are as follows:

Resident (R1) was found on the floor in their room on 4/7/25 (12:40 am) and stated to facility staff they had been pushed by their roommate, (R2), when walking out of the bathroom of their room. Both (R1) and (R2) were sent to the emergency room for further medical evaluation. (R1) was diagnosed with a right femoral neck fracture and admitted at that time. Surgery was performed on 4/7/25 and (R1) was discharged to a skilled nursing facility on 4/10/25.
*cont on 9099C-1..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
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 4
Control Number 59-AS-20250408122042
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: 08/04/2025
NARRATIVE
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9099C-1.. (R2) was sent to the emergency room on 4/7/25 following the altercation with (R1) for further medical evaluation. Facility charting notes document (R2) returned to the facility on 4/7/25 (4:56 pm) with medication changes and indicate that (R2) had 1:1 care/supervision for the NOC shift of 4/7/25 to 4/8/25, and staff will be doing alert charting and behavioral charting on (R2). Notes further document at 4/9/25 (2:36 pm) that "(R2) took all medications and 1 on 1 care has been with resident all shift", and on 4/9/25 (9:47 pm) that resident has "had no issues out of baseline; med compliant and eaten all meals". Notes state on 4/10/25 (2:28 pm) that "(R2) will continued to be monitored with a 1:1 and resident's behavior/location to continued to be monitored every 30 minutes round the clock".

Staff interviews concluded that (R2) has a history of aggression with staff in the past and has pushed another resident prior to this incident. (R2) also consistently wanders throughout the community and shows exit seeking behaviors. Several staff conveyed in interviews that (R2) should not have been admitted to the facility based on their care needs, as they need specialized care that Citrus Heights Terrace cannot provide.
The Department was told by three different staff that (R2) should have been placed in a higher level of care such as a skilled nursing facility. The facility had to implement 1:1 care for (R2), which is not a service the facility provides and was hiring an outside agency to fulfill the 1:1 care role.

Based on this investigation, the allegation is substantiated that the facility failed to provide adequate care and supervision. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. (R2), who has a known history of aggression towards residents and staff, was not placed on one-on-one (1:1) supervision until following the latest unprovoked assault which resulted in (R1) sustaining a right hip fracture.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page along with a civil penalty for a repeat violation.

An immediate civil penalty in the amount of $500.00 is 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.
*cont on 9099C-2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250408122042
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: 08/04/2025
NARRATIVE
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9099C-2.. At the time of the complaint inspection on August, 4, 2025, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49.

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

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250408122042
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: 08/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2025
Section Cited
CCR
87411(a)
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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:
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LIcensee/Administrator agree to provide in-staff training on 8/8/2025 relating to 1:1 care/supervision for residents when needed. Documentation of training due by 8/9/25.

Administrator previously conducted staff trainings on 4/29/25; 6/11/25 and 7/11/25 aggressive behaviors; 7/25/25 aggressive behaviors and dementia.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that adequate supervision was provided to (R2), prior to April 7, 2025 (12:40 am) when (R2) pushed (R1) in their room), causing (R1) to sustain a right femur neck fracture, which posed an immediate health and safety risk to residents in care.
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A civil penalty in the amount of $500.00 is being assesed- due to this being a repeated violation, an additional $500.00, for a total of $1,000.00, is being assessed in this report.
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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: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4