Citrus Heights Terrace

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to close a complaint received on-line and anonymously on 07/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegations with the Administrator, RCC and a Med-Tech staff and toured the facility on several different occasions. LPA went into multiple resident rooms, including the room referenced in the complaint, and also checked several residents's bedding to see if it was soiled. The results are as follows: Allegation: Staff are mishandling resident's medications. The complaint alleges there were medications seen in resident’s room (shared by R1 and R2) when visiting one of the residents. *cont on 9099C-1... UnfoundedRead the full finding— CDSS inspection report, October 24, 2023 · control 59-AS-20230726152403

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint received anonymously on-line on 10/17/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegation(s) with the Administrator, Resident Care Coordinator (RCC) and the Maintenance Director. LPA, RCC and (1) Med-Tech staff reviewed medications for (5) residents whose room numbers were referenced in the complaint and also tested random resident pull cords in individual bathrooms. The results are as follows: Allegation: Staff are mishandling the residents medications. Complaint alleges that medications have been out for a month for residents who occupy (4) specific rooms. The Narc count is off and is not accurate Norco and lorazepam is off *cont on 9099C-1... UnfoundedRead the full finding— CDSS inspection report, October 24, 2023 · control 59-AS-20231017114128

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation deliver findings to a complaint, received on 7/18/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) staff and (2) residents. LPA reviewed the incident report binder organized for months April -August 2023. The results of the investigation are as follows: Allegation: Staff was verbally abusive to a resident. The complaint alleges a family member witnessed staff being verbally mean to the residents. There is no date, time or resident names referenced for this allegation. One staff stated on 7/20/23 there is no verbal abuse ever but she will speak firmly with the residents since they have Dementia. A second staff who has worked at the community for many months stated he is not **cont on 9099C-1... UnfoundedRead the full finding— CDSS inspection report, October 17, 2023 · control 59-AS-20230718104900

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/18/23, for the above allegation. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA discussed the allegation with the current Administrator, Interim Administrator, Resident Care Coordinator (RCC), (4) staff and reviewed the Incident Binder. Administrator reviewed staff training on the computer and confirmed that all staff have completed coursework in Abuse, Neglect and Explotation in an Elder Care Setting and Resident Rights, Personal Rights and Ethics. Mandated reporting is discussed in these (3) courses. Allegation: Licensee is not following reporting requirement. The complaint alleges that a manager told staff last week not to report, and incidents are not being reported as required. There are no specifics included in the complaint and the complainant is anonymous. cont on 9099C-1.Read the full finding— CDSS inspection report, October 17, 2023 · control 59-AS-20230718114857

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint, received on 7/25/23, for the above allegations. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) Med-Tech staff and (1) caregiver staff. LPA reviewed the Narcotic Shift Count log from April- August, 2023, and the Controlled Substance Record from January- August, 2023. LPA also reviewed the October shower log. The results of the investigation are as follows: Allegation: Staff are falsifying residents' records. The anonymous complaintant alleges the narcotic count was off, and he/she was told to correct it when it wasn't that staff that made the mistake. cont on 9099C-1... UnfoundedRead the full finding— CDSS inspection report, October 17, 2023 · control 59-AS-20230725143417

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegation and met with Resident Care Cordinator (RCC), Ashley Astahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. The complaint identified R1 as a resident who did not receive adequate incontinence care and oral hygiene. Records review and interviews found that R1 was discharged in May 2023. The allegation did not state specicific dates or caregivers alleged to not provide care. Interviews found that R1 would need 1-2 staff for incontinence care. While R1 required a high level of physical assist, R1 could usually idenify when they needed incontinence care. Because R1 had frequent incontinence assistance, staff had a schedule of care and checked in with R1 often between schedule care. UnsubstantiatedRead the full finding— CDSS inspection report, October 12, 2023 · control 59-AS-20230720164140

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Ashley Stahl, RCC, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Staff are mismanaging resident's medications- The allegations did not provide specific timelines for when events were alleged to have occured. The alegation of medication mismanagement has been investigated as well by LPA Calzada in concurrent complaints and was substantiated for 87465(a)(4) failures to provide medications as prescribed. Citations were issued on7/20/23, 7/31/23, 8/9/23 and 9/29/23 for related issues that are currently in plans of correction. Therefore an addiional citation is not issued at this time. Regarding Staff are not keeping accurate medication records- Interviews and records reviews found regular lack of consistent and complete recording of PRN use for residents as required. SuRead the full finding— CDSS inspection report, October 12, 2023 · control 59-AS-20230823082439

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that an altercation occurred between two residents. A date or time was not identified, niether were the residents alleged to be involved. Only that it occured near R1's room and the other resident allegedly stated R1 had hit them. Records reviews and interviews found R1 to have dementia with behavioral disturbance. Staff notes for a period around when the time thecomplaint was made, found no record of such an incident. Interviews found that R1 may raise their voice and swat at staff, staff generally have not witnessed events of R1 hitting other residents. All staff interviewed stated that it could be possible for R1 to strike at another resident who is in R1's sRead the full finding— CDSS inspection report, October 12, 2023 · control 59-AS-20230828113616

On 10/12/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with RCC Ashley Stahl. LPA conducted records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. It was alleged that staff do not receive training as required. A period of time was not identified, niether were the staff alleged to not be trained. LPA reviewed August 2023 staff schedules and a review of staff training- particularly staff who began to work at the facility in Aug 2023. S1 and S2 had the required 20 hours of training before working with residents. Their training is ongoing. Interviews of caregivers with whom S1 and S2 worked stated that all new employees undergo a period of training, without individual care assignments, until they demonstrate compitency. UnsubstantiatedRead the full finding— CDSS inspection report, October 12, 2023 · control 59-AS-20230830113344

**This page was amended on 10/4/23 to note that all requested documentation was received as requested during the investigation. A new signature was also obtained.** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver investigative findings to a a complaint received on 5/4/23. LPA met with Med-Tech, Gina Yanez (GY), who stated the Administrator, Toni Jones, was temporarily out of the building conducting a new resident assessment but would return shortly. LPA met with the Administrator at 1:45 pm. During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (RCC), (2) family members of resident (R1), and the Maintenance Director. LPA reviewed documentation pertaining to (R1), including but not limited to, physician's report, care plan, charting notes, and incident reports, Medication Administration Record (MAR), Admission Agreement. The results of the investigation are as follows: **cont on 9099C-1... SubstantiatedRead the full finding— CDSS inspection report, September 29, 2023 · control 59-AS-20230504081443

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint received anonymously on-line on 09/26/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. During today's inspection, LPA discussed the allegations with the Administrator and (2) staff. LPA also inspected the shared room that is referenced in the complaint with the Administrator and attempted to speak to both residents who occupy it. The results of the investigation are as follows: cont on 9099C-1.. Unfounded— CDSS inspection report, September 26, 2023 · control 59-AS-20230921164843

Licensing Program Analyst (LPA) Sabrina Calzada and Associate Government Program Analyst (AGPA) Brian Lam arrived unannounced to open and close a complaint received anonymously on 09/05/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegations with the Administrator, Activities Director, Maintenance Director, (2) culinary staff, (1) housekeeper and (1) caregiver and toured the interior of the facility, including the common areas, (4) random resident bedrooms and (2) dining rooms, and the staff breakroom. The results of the investigation are as follows: Allegation: Staff do not properly maintain a resident's room while in care. The anonymous complaint did not provide a specific resident name or room number and only says a female resident's room and the carpet smell of urine. LPA conducted a tour of the common areas and resident rooms and did not observe any strong incontinent odors and the carpets were observed to be cleaned recentlyRead the full finding— CDSS inspection report, September 7, 2023 · control 59-AS-20230905164202

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/18/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA also briefly met wiith Ashley Stahl, Resident Care Coordinator (RCC). LPA discussed the allegation with the Administrator, RCC and (2) caregivers. LPA observed resident rooms of residents who had a diagnosis of scabies and reviewed documentation. The results of the investigation are as follows: LPA was informed of a scabies outbreak with (2) residents on 8/9/23, when resident (R1) was sent to the ER due to showing signs of itching and having a rash on her body. R1 returned the same day but without a diagnosis of scabies. R2 was also sent to the ER on 8/9/23 due to itching and having a rash that covered her whole body. R2 returned the same day with a diagnosis of scabies and prescription creme for treatment. LPA received a completed incident report (LIC624) for R1 and R2 onRead the full finding— CDSS inspection report, August 22, 2023 · control 59-AS-20230818104727

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/18/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegation with the Administrator, RCC and (2) caregivers. LPA reviewed documentation from resident (R1) who is the subject of the complaint. The results of the investigation are as follows: Complaint alleges that resident is having urine infections due to not staying dry. Administrator confirmed that there is no record of resident having a recent urinary tract infection (UTI). Both the RCC and a Med-Tech staff stated that R1 had a UTI several months ago, and the only recent medical intervention has been bladder surgery and follow up care for removing a catheter. cont on 9099C-1... UnfoundedRead the full finding— CDSS inspection report, August 22, 2023 · control 59-AS-20230817142551

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 8/15/23. LPA met with Toni Jones, Administrator, and explained purpose of inspection. LPA discussed the allegations with the Administrator, RCC and (1) Med-Tech. The results of the investigation are as follows: Complaint alleges that a new male resident keeps leaving the building. There is no resident name provided in the anonymous complaint. All staff interviews revealed that the last time a resident eloped from the facility was on 6/29/23 (7:30 pm), the same day that same resident moved to the community. There have been no additional elopements. Based on information obtained, LPA finds the allegation to be UNFOUNDED. cont on 9099C1. UnfoundedRead the full finding— CDSS inspection report, August 22, 2023 · control 59-AS-20230815101443

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Ashika Bennanon, Med-Tech, who stepped out of the staff meeting taking place and directed LPA to an empty office area. LPA later met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. LPA observed a resident (R2) being taken by a non-emergency ambulance provider to the hospital for medical attention. Also occuring during today's inspection was the fire department arriving due to the smell of smoke coming from inside resident walls in two rooms. The source of the smoke was determined to be related to a repair made by an HVAC company yesterday. Residents were moved to the other side of the building and no one was injured. During today's inspection, LPA discussed then allegation with RCC and (3) Med-Tech staff. LPA also reviewed medication documentation pertaining to resident (R1). The results of the investigationRead the full finding— CDSS inspection report, August 9, 2023 · control 59-AS-20230807090749

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation received anonymously on 89/3/23. LPA met with Ashika Bennanon, Med-Tech, who stepped out of the staff meeting taking place and directed LPA to an empty office area. LPA later met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. LPA observed a resident (R2) being taken by a non-emergency ambulance provider to the hospital for medical attention. During today's inspection, LPA interviewed the RCC and (1) staff. LPA also reviewed notes from the Ombudsman's visit to the facility on 8/4/23 regarding the alleged incident. The results of the investigation are as follows: Allegation: Staff yelled at resident. Complaint alleges that a random driver was stopped on the side of the ride to use the navigation system in his/her car and heard a female staff yell at a resident by the gate. Allegation also states the staff was blonde-haired. **cont on 9099C-1... UnRead the full finding— CDSS inspection report, August 9, 2023 · control 59-AS-20230803082156

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Ashley Stahl, Resident Care Coordinator (RCC) and explained purpose of inspection. Also present in RCC's office was Ashika Bennanon, Med-Tech. During today's LPA discussed allegation with RCC and Med-Tech staff. LPA stated the complaint received on 7/28/23 was filed anonymously and only references a male resident with no specific information as to the resident's name or room number. The complaint alleges a resident was administered narcotics,specifically Norco, incorrectly. RCC provided names of the male residents and stated that resident (R1) recently had a missing bottle of Norco (Hydrocodone) 325-5 mg, and R1 refuses medications and hospice is aware. Med-Tech stated that several of these residents take Lorazepam and one resident takes Morphine. cont on 9099C1... SubstantiatedRead the full finding— CDSS inspection report, July 31, 2023 · control 59-AS-20230728133706

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the complaint investigation and deliver findings for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. During the investigation, LPA interviewed (2) Med-Tech staff and the Administrator. LPA interviewed (1) resident and attempted to interview (2) residents but was unable to obtain any pertinent information. LPA also reviewed medications being administered to (3) residents, including the associated orders and documentation, and toured the interior of the community. The results of the investigation are as follows: Both Med-Techs stated they occasionally do find a pill or medication on the floor as there are a couple of residents who pretend to take their medication and "pocket it", but most residents “know their routine” and are generally good at taking their medication. One Med-Tech indicated that she and other staff do document when a residentRead the full finding— CDSS inspection report, July 20, 2023 · control 59-AS-20230626105103

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 4/12/23. The allegation: Resident sustained pressure injuries while in care was investigated by the Department and LPA investigated the remaining (4) allegations. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. T During the investigation, the Department conducted interviews and reviewed documentation, including medical records. The results of the investigation are as follows: Resident (R1) was admitted to the facility on 10/6/2021 from a skilled nursing after being hospitalized. Resident had been receiving home health services for an extended period of time before being hospitalized. A wound was noted on 10/5/21 on resident's right foot; a second wound was not noted until January 2022. In June 2022, resident had an annual assessment and Physical Therapy was recommended. Resident was admitted to the SNF in early June 2022 and wasRead the full finding— CDSS inspection report, July 20, 2023 · control 59-AS-20230412085616

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. LPA also observed an Ombudsman staff to be present at the facility at the start of the inspection. During today's inspection, LPA interviewed Administrator, Resident Care Coordinator (RCC), (1) Med-Tech staff. Ombudsman was present when (2) residents were observed and attempted to be interviewed regarding recent bruising they sustained from unwitnessed falls. LPA reviewed resident files and incident reports submitted for each resident following an unwitnessed fall. The results of the investigation are as follows: The Department received an anonymous complaint on 7/10/23 alleging "there are two residents that have really big bruises on their face and one resident that got hurt". There were no details provided as to resident names, dates of injuries, or staff names or witRead the full finding— CDSS inspection report, July 13, 2023 · control 59-AS-20230710094256

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint investigation for the above allegation. LPA met with Editha McCullough, Interim Administrator, and explained purpose of inspection. During today's inspection, LPA interviewed Interim Administrator, Resident Care Coordinator (RCC), and the Maintenance Director. LPA reviewed the incident report (LIC624) submitted to the Department on 6/30/2023 as well as resident (R1's) physician's report, care plan and other paperwork. The results of the investigation are as follows: Both the Administrator and RCC stated resident had just moved to the community on 6/29/2023 when he eloped later that evening, at approximately 7:30 pm. LIC624 states that resident was discovered missing by a med-tech who had entered resident's room to administer medications. All staff were immediately informed and began searching for the resident inside and outside of the community. ***cont on 9099C(1).. SubstantiatedRead the full finding— CDSS inspection report, July 6, 2023 · control 59-AS-20230629113804

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint report received on 1/18/2023. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, was screened per Covid-19 precautionary measures upon entering the facility and wore the following Personal Protective Equipment (PPE): surgical mask. The results of the investigation are as follows: During the investigation, LPA interviewed the following facility staff: Administrator, Resident Care Coordinator (RCC), (2) caregiver staff, and (2) residents. LPA also interviewed (2) individuals who are employed by an outside health care provider. LPA reviewed facility documentation related to residents (R1 and R2) and medical documentation related to resident's (R1) injury referenced in the complaint report.. The results of the investigation are as follows: cont on 9099C(1)... UnsubstanRead the full finding— CDSS inspection report, February 23, 2023 · control 25-AS-20230118102646

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 9/19/2022. LPA met with Tina Prewitt, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical mask. During the investigation, the Department interviewed multiple facility staff members, residents, including resident (R1), as well as several individuals who had knowledge related to the allegation. In addition, the Department reviewed resident's (R1) documentation on file at the faciltiy and hospital medical records. The results of the investigation are as follows: cont on 9099C(1)... UnfoundedRead the full finding— CDSS inspection report, December 22, 2022 · control 25-AS-20220919142458

On 12/3/2021, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 25-AS-20210720093422. LPA met with Tina Newton, Executive Director, and explained the reason for the visit. Prior to initiating the visit, LPA completed the required COVID-19 Testing Protocols, and a daily self- screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a mask was worn for Personal Protective Equipment (PPE). Additionally, LPA was screened by front desk personnel. Throughout the course of the investigation, the Department reviewed facility notes, conducted interviews with residents and staff, reviewed resident file, and obtained relevant documentation and evidence. LPA interviewed 5 staff and 5 residents who all report that they have never witnessed any residents to not have their needs met. AllRead the full finding— CDSS inspection report, December 3, 2021 · control 25-AS-20210720093422