Citrus Heights Senior Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with staff, Onejeh Jones and Jackie Cole-Cochrane. LPA stated the reason for the inspection was to follow up on (2) incident reports recently submitted to the Department. LPA discussed the incident reports (2) with the Administrator, by phone. All residents were napping in their rooms. On May 26, 2026, the administrator received a phone call from the day program that resident (R1) reported that facility staff had taken their cigarettes. Staff Jones stated she found the alleged missing cigarettes (1 pack) under (R1's) pillow. The administrator stated (R1) short-term memory loss and is confused/disoriented some of the time, and (R1) has a habit of misplacing items often. The administrator stated the new issue with (R1) is a friend gives (R1) more cigarettes while they are attending day program, but doesn't give them to the staff when returning to the care home. (R1) is aware of the house rules now and will allow staff to safeguard, with a lighter, and ask for them, when desired. Staff Jones showed LPA a large ziploc bag where multiple packs of cigarettes and a lighter are securely stored. On May 26, 2026, resident (R2) received a full shower after the hospice nurse provided clearance. (R2) received bed baths due to transfer concerns related to a very swollen ankle when moving in in April 2026. After this bath, (R2) tried to get up multiple times, but staff told her to call for assistance. (R2) was able to slide to the end of the bed and sustain a skin tear and sore back while slipping out of bed. Hospice staff was notified and arrived to provide first aid/skin tear care. Staff Jones stated the hospice nurse was last here Wednesday, this week, and changed the dressing. LPA observed bed pads covering full bed rails on (R2's) bed. LPA also observed (R2) to be resting comfortably and wearing clean dressing on their left forearm. The administrator and staff continually remind (R2) to use their call button, and staff regularly check on (R2), leaving the door open. It appears the facility took appropriate and timely action in both incidents. There are no deficiencies issued in this report. Exit interview with Staff Jones. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 5, 2026

Allegation investigated: Staff are locking resident in their room.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on April 21, 2026. LPA met with Sukh Sahota, Administrator, and stated the reason for the inspection. LPA observed (2) residents present in the common area and (2) residents resting in their rooms and was advised (1) resident was attending a day program. LPA observed (2) visitors arrive for a resident and staff, Jackie Cole-Cochrane preparing lunch. During the investigation, LPA interviewed the Administrator, an acquaintance of staff (S1), a family member of resident (R1) and resident (R2). LPA was unable to interview resident (R1) and staff (S1 and S2), who last worked at the facility through on/around March 31, 2026. LPA reviewed documentation including (R1's) Pre-Appraisal, Physician's Report and other notes. The results of the investigation are as follows: *cont on 9099C-1.. Substantiated 9099C-1.. Resident (R1) moved to the facility on March 17, 2025 with a primary diagnosis of Alzheimer's Dementia. The Physician's Report notes that (R1) could be confused/disoriented, exhibits wandering/sundowning behaviors and is an "elopement risk". Additionally the report notes (R1) is ambulatory, not able to leave the facility unassisted, and requires assistance with bathing and medications. Allegation: Staff are locking resident in their room. The allegation states there is a resident (R1) who is locked in their room after hours to prevent them from leaving the facility since throughout the day the resident would attempt to elope. The Administrator stated prior staff (S2) placed a lock on (R1's) door for approximately a week and he was not aware of this as (S2) did not tell him. The administrator explained it was (S2's) job to check on (R1) at night", stating "(S2) would sleep through" (R1) getting up, exiting through the front door, and not get up when the "alarm went off" and "(S1) would have to go after (R1)". After (S1) left the facility, (S2) put a lock on (R1's) bedroom door at night". The administrator stated he removed the knob to turn the lock and disabled the locking mechanism, over a year ago, when he found out about this as (S2) quit. Resident (R1) was asked if there was ever a lock on their bedroom door and was not able to articulate well and provide an answer, but appeared pleasantly confused. (R1's) family member stated she was not aware of a lock ever being on (R1's) door and (R1) did not say anything to her about it. LPA observed the door knob on (R1's) door, and all other resident doors, to not have a locking mechanism in place when inspected on April 21, 2026 or on May 19, 2026. Based on information obtained, the allegation is found 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. Copy of report provided. 9099A-C-1.. The administrator confirmed that (R1) has a diagnosis of Dementia and only exited the door on one occasion, on March 31, 2026, (around 12:00 pm) when he was on the phone requesting emergency medical services for staff (S1). The administrator explained the paramedics had just arrived and saw (R1) who had just walked out the door and the fireman asked (R1) if they were okay. A neighbor was outside near the driveway, recognized (R1), and stayed with them for (2) minutes or less, until the administrator came outside. The administrator confirmed he had (3) total residents at that time, and he was the only staff on shift. A family member of (R1) was asked if (R1) ever left the facility unassisted and stated "No, (R1) never left unattended that I'm aware of" and insisted that (R1) "never went in the forest " across the street but explained that (R1) has an "outside contractor" through a third party that takes (R1) to the movies every other week. The family member explained that on the last outing with one particular caregiver, (R1) "didn't want to go to the movies with him", got out of the car and went to the forest area across the street". The family member explained that this outside caregiver "didn't even go get (R1) but went to tell the caregiver in the facility", who went across the street to get (R1). The administrator stated that when this incident occurred, the outside caregiver signed (R1) out of the facility before getting in the car. Staff (S1 and S2) were not available for an interview. (R1) indicated that they like to go to the forest but was not able to provide LPA with additional information. Another current resident (R3) stated they have "never seen (R1) leave or try to leave" the facility and confirmed there are auditory alarms on each exit door. The administrator tested the front door door alarm on April 21, 2026 during the inspection, and. LPA heard the alarm sound. LPA also heard the alarm used at nighttime, which was significantly louder. Based on information obtained, the 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.the state’s words, verbatim · CDSS document, May 19, 2026 · control 59-AS-20260421151442

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jun 2, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that staff (S2) did not place a lock on (R1's) door at night, for approximately a week, which presented a potential personal rights violation. The locking mechanism was placed on/around the end of May 2025 or beginning of June 2025,the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Licensee/Administrator stated he disabled the locking mechanism immediately upon finding out about it. Licensee/Administrator agrees to conduct staff training with current staff to ensure this does not occur again. Topics will be on personal rights and elopement prevention. Documentation of staff training to be provided to the Department by 6/2/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Sherry Cort, Administrator Designee. Also present was Arshdeep Kaur, volunteer staff. Administrator Sukhman Sahota arrived around 11:15 am. LPA observed (1) resident leave with a family member to go on an outing and (3) residents resting in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents, (1) of whom may be bedridden, and has a hospice waiver for (2) residents. Currently no residents are under hospice care. LPA and Administrator Designee toured the interior/exterior of the facility, including common area, resident bedrooms, (3) resident bathrooms, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. The bathrooms have the necessary grab bars, non-skid flooring, soap, and paper towels. There are locked sharps, toxins and medications in the kitchen. There is sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Hot water measured 113.5*F in the kitchen. Fire extinguisher was last serviced on 9/24/2025, and there is a complete First Aid kit. All exit doors have alarms. There are sufficient PPE/paper supplies and linens/towels/blankets as well as flashlights and night lighting. There are multiple required postings posted near the front entrance, including the Emergency Disaster Plan and Theft & Loss Policy. There are games/activities and an operating land line. There is a covered patio with table and chairs and (2) unlocked exit gates. There are storage sheds. LPA reviewed (4) of (4) resident files and (2) staff files. Files were organized and contained current documents. Medications were reviewed for (2) residents- medications are being logged appropriately. Administrator to request updated medication lists for (2) residents. Staff have completed required training, including First Aid/CPR, and RCFE Administrator Certificate #6072086740-exp 9/30/2026. *cont on 809C-1. 809C- Discussed updated Dementia regulations and paperwork to be obtained for Plan of Operations. Discussed annual fees due by 1/7/26. LPA to provide log-in information to pay on-line by email following the inspection. LPA did not observe any obstructions to any facility doors. LPA confirmed that staff are aware of where utility shut-off valves are. There were no deficiencies observed. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 5, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Sherry Cort, Administrator Designee. Administrator Sukhman Sahota arrived around 11:15 am. There are (4) residents who currently live at the facility; (1) resident was out of the community for an outing. This report is being created to clear the Post-Licensing inspection in the system. There were no deficiencies observed. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Facility staff are not providing adequate food services. Facility staff are not providing assistance with ADLs. Facility staff are violating resident's personal rights.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint invetigation and deliver findings. LPA met with Administrator, Sukh Sahota, and stated the purpose of today's inspection. Also present was Deep Kaur, volunteer. LPA observed (4) residents resting in their private rooms and was advised (1) resident was out of the facility for the afternoon. During the investigation, LPA interviewed the Administrator, (2) facility staff, resident (R1), (3) other residents and an individual who knows (R1). LPA reviewed pertinent documentation, including but not limited to, (R1's) physician's report, Pre-appraisal, and hospital discharge paperwork. The results are as follows: *cont on 9099C-1.. Unfounded 9099C-1 Allegation: Facility staff are not providing adequate food services. The allegation states resident (R1) was not being fed healthy meals. One staff stated (R1) did not have a special diet but had "no teeth" so was served "soft fruits" along with all the same foods other residents were offered. This staff added (R1) has no dentures currently but bought ribs from the grocery store and asked this staff to prepare them. A second staff stated "sometimes (R1) will eat" and would often gives fruits to (R2), adding (R1) asks for soda, coffee and won't drink water. The physician's report notes (R1) did not have a special diet and the facility confirmed (R1) was served the same food as all other residents and didn't have a problem eating any food, except for hard fruit such as apples. The Administrator stated there is a two week, rotating menu, and (R1) "did not complain to him about meals, but (R1) will say if they don't like something- we always offered (R1) an alternative such as a grilled cheese, chicken/tuna sandwich. An individual who knows (R1) stated (R1) would complain about food served to him when living with their family member and staying at the hospital. All individuals interviewed stated that (R1) would often refuse meals and go outside on the patio and smoke. Resident (R1) stated they were in a "deep depression" when living at the facility and lost 100 pounds in a few months after their daughter passed. The Administrator stated (R1) maintained the same weight and maybe have 5-10 pounds in just 2 months. LPA observed fresh produce on hand and being served with lunch on 8/29/25. LPA interviewed (3) additional residents who indicated the food served is of good quality and variety, and low-salt options are offered. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Facility staff are not providing assistance with ADLs. The allegation states the facility was not allowing (R1) to shower without staff assisting and staff was not monitoring (R1's) blood pressure. Staff stated (R1) would refuse showers, but they were able to ensure (R1) received a shower at least weekly. The Administrator stated staff would ensure (R1) received a shower at least twice weekly. (R1) stated staff helped him several times in the shower; however, he was not comfortable with female staff helping him, and the Administrator explained to (R1) that "he was afraid I would fall". (R1) stated they took a shower with no assistance before and didn't fall, and realizes now the Administrator was "trying to help".*cont 9099C-2.. 9099C-2.. One staff explained that (R1) "keeps insisting that they can do everything themselves" and when Sukh is here, he will try and "encourage (R1) to shower- sometimes (R1) will agree". The Administrator stated (R1) never expressed that they were uncomfortable with female staff giving a shower. An individual who has knows (R1) stated "(R1) would never try and shower when they lived with their family, would wear dirty clothes and this is not new behavior". Additional residents stated care is being provided as needed and staff are very helpful. This portion of the allegation is found to be unfounded. The Administrator stated on 8/29/25 that he just received a verbal blood pressure order 3-4 days ago from (R1) and (R1) has been at the casino the last 2 days". The Administrator stated a doctor's order was never received to take (R1's) blood pressure. The facility provided documentation showing (R1's) blood pressure was taken daily starting on 7/25/25 through 7/29/25 and then daily from 8/1/25 through 8/16/25. Readings varied between low, normal and high. The Administrator decided to document blood pressure readings beginning on 7/25/25 to be able to chart any changes to convey to the doctor. Blood pressure was also taken for other residents on/around end of July 2025 to chart their health status. One staff stated (R1) is hardly at the facility and leaves at 7:00 am, missing breakfast, lunch and dinner. This staff explained that (R1) "just leaves and will not say when they will be back but talks to Sukh" and that (R1) left two days ago and he did not take any medications with him. (R1) stated staff were not checking their blood pressure as much as they were "supposed to", commenting staff had taken it "daily" before, acknowledging the order came later after they went to the Emergency Room in August 2025. The Administrator stated there was never a time when (R1) asked for their blood pressure to be taken and it was not taken by the facility. This portion of the allegation is found to also be unfounded. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. *cont on 9099C-3... . 9099C--3.. Allegation: Facility staff are violating resident's personal rights. The allegation states the facility staff is not allowing (R1) to leave and return to the facility when they choose. Both staff indicated that they have never told (R1) they could not leave the facility by themselves but asked that ( R1) does not if their legs were "shaky" or (R1) was not walking with a steady gait. One staff stated she would call the Administrator who would tell (R1) that they shouldn't go", explaining it takes (3) firemen to pick (R1) up and (R1) fell outside on many occasions. Another individual who knows (R1) stated "if staff see (R1) is in a bad state they may tell (R1) not to go" and commented that the facility has a curfew for a reason. (R1) stated that the Administrator, Sukh, said they couldn't leave if their legs were shaky and realizes now the staff "were doing things for my good- everything was for my own good, and I didn't realize it". (R1) commented "99% was my fault". Three other residents indicated they do not feel their personal rights have been violated in any way. The physician's report (dated 6/2/25), notes (R1) is able to leave the facility by themselves. (R1) received an updated physician's report (dated 9/9/25) notes (R1) is not able to leave the facility unattended. Based on information obtained, LPA finds the allegation to be UNFOUNDED-meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 59-AS-20250828162735

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived announced to conduct a scheduled pre-licensing inspection for a change in ownership. LPA met with Sukhman Sahota, Administrator. Also present was Sherry Cort, staff, who was preparing food in the kitchen. There is a pending license for (6) non-ambulatory residents, (1) of whom may be bedridden. There are currently (5) residents who reside at the facility, and (1) resident is under hospice care. (4) residents were present during the inspection. LPA and Administrator toured the interior and exterior of the facility, including common area, resident bedrooms, (3) resident bathrooms, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. The bathrooms have the necessary grab bars, non-skid flooring, soap, and paper towels. Hand-washing posters (20+ seconds) to be posted near each sink. There are locked sharps, toxins and medications in the kitchen. There is sufficient 2+day perishable and 7+day non-perishable supply of food. Hot water measured 115*F in a resident bathroom and the inside temperature measured 73*F. Fire extinguisher was last serviced on 10/7/24, and the smoke/monoxide alarms are in working order. All exit doors have alarms. There are sufficient PPE/paper supplies and linens/towels/blankets as well as flashlights and night lighting. There are multiple required postings posted near the front entrance, including the Emergency Disaster Plan and Theft & Loss Policy. There are games/activities and an operating land line. There is a covered patio with table and chairs and (2) unlocked exit gates. There is a complete First Aid kit and a menu and activity calendar is posted in the kitchen. LPA reviewed (1) resident file and one large staff binder for personnel records. Files were organized and contained current information. The facility has an active subscription with an approved on-line vendor for staff training. The current land line phone number was obtained. Discussed obtaining Guardian access to manage staff rosters. LPA provided an informational page on Updates to Dementia Care and Miscellaneous Changes effective 1/1/25, and the website/email addresses for CCLD and LTCO to include in the Admission Agreement. Component III was reviewed during today’s inspection. Pre-Licensing is complete and this facility has no deficiencies. Exit interview. Copy of report left at facility. LPA to notify to the Centralized Applications Bureau.the state’s words, verbatim · CDSS document, Jan 2, 2025