Twin Rivers at Natomas

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hiratsuka arrived at the facility to conduct a required annual inspection. LPA met with Administrator and Licenseet. LPA and Administrator conducted a tour of the interior of the facility. Areas toured included but not limited to: six (6) residents room, dining room, activity room, laundry room, shower room, kitchen and the common areas. LPA observed kitchen to be restricted to staff only. LPA was informed that if cook is not present then door will be locked for remainder of time. LPA observed present of two days of perishable and seven days of nonperishable foods. LPA observed facility to have ample supply of linens, and hand sanitizers throughout the facility. LPA observed residents room to be free of sharps, toxins and medications. LPA was informed that medications are centrally stored unless stated otherwise by physician order and/or physician's report. File review was conducted for four resident records and four personnel records. LPA observed resident records to have the required documents. LPA observed staff files to be complete. During today's visit the following topics were discussed: -Licensee inquired about obtaining a locked perimeter waiver. -medication policies -other topics. Facility meets Title 22 regulations. No deficiencies cited.the state’s words, verbatim · CDSS document, Jun 3, 2026

Allegation investigated: Staff member engaged in inappropriate activity with resident in care. Staff mismanage residents' medications.

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the findings for the allegations cited above. LPA met with Assistant Administrator and explained the purpose of the visit. For allegation of Staff member engaged in inappropriate activity with resident in care, based on interview conducted with resident (R1) it revealed that R1 did text staff (S1) outside of work hours but it was not sexual. R1 then deleted most of the text messages as advised by S1. R1 was adamant the relationship was platonic. Based on the text messages LPA observed from R1's phone, it revealed that S1 was texting R1 good night along with emojis. For allegation of Staff mismanage residents' medications, based on interviews conducted with medication technicians, it revealed that part of the policy is to confirm that residents consumed the medication before leaving the room. Interview with MT1 and MT3 revealed there was times where residents did not have enough water where they had to leave the room to retrieve water pitcher from the medication cart. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Exit interview. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2026 · control 59-AS-20260113121743

Allegation investigated: . Facility is malodorous. 2. Facility is not ensuring that residents utilize resident's assistive devices. 3. Facility staff are not ensuring to protect resident's property.

LPA Hiratsuka conducted the investigation into the allegations above. LPA Hiratsuka conducted interviews, reviewed files, and walked around. 1. LPA observed one resident's room to have a urine smell. LPA observed staff were still in the process of cleaning resident rooms. Once the bed was changed the smell disapated. Staff stated they check on residents every two hours or as needed and this one room both residents can be difficult with assistance to use the bathroom and incontinent care during the hours the residents sleep. LPA and administrator discussed options and other ways to assist the residents with incontinent care. LPA cannot prove or disprove the staff are not keeping the facility free of odors due to not cleaning. LPA did not observe any other issues with the physical plant. Unsubstantiated 2. and 3. LPA interviewed the resident in question. The device in question is a pair of glasses. The staff stated the resident does not like wearing glasses. LPA observed the resident doing an activity and did not appear to require glasses for the activity. LPA asked the resident if they wanted to put their glasses on the and the resident said no. LPA observed the resident walking around and not bumping into things. Staff stated the resident will put on the glasses if reminded but will take them off very shortly or sometimes refuse to wear them. Staff stated the resident also misplaces the glasses and won't tell the staff where the glasses are. LPA observed the staff this morning looking for the glasses. The staff stated the resident takes them off and puts them wherever they choose. Staff stated they know the resident wore them the other day and has not gone anywhere. Staff stated they check the trash cans before the trash is thrown out. LPA cannot prove or disprove staff do not assist the resident with wearing the glasses or safeguards the glasses based on the resident's capabilities. LPA and administrator discussed several ways to document resident abilities and capabilities with adaptive devices. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 59-AS-20251229130101

Allegation investigated: Staff do not ensure the residents are served nutritious meals

On February 25, 2026, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct an investigation regarding the allegation cited above. LPA met with Administrator and explained the purpose of the visit. Allegation of: Staff do not ensure the residents are served nutritious meals, the Department conducted interview with Administrator, which revealed that staff do eat the leftover food but do not serve themselves first. It was mentioned by a cook that after dinner was served, residents were able to receive a second round of Sloppy Joes. Once confirmed that all residents were full, leftovers were given to staff. Then shortly afterwards, a resident stated they wanted another Sloppy Joe as well but there was none more. Cook did offer to make resident an alternative meal of grilled cheese which resident accepted. Interview conducted with facility cook revealed that meals at the facility are not for staff unless at the end if there is an overflow. Please continue LIC 9099-C. Unfounded Interview further revealed that alternative meals are offered to residents if they are still hungry. Interview conducted with Administrator Assistant revealed that facility serves meal three times a day, with snack in between. Additionally at the end of night, basic sandwiches are made and stored in the medication room for residents to consume if hungry throughout the night. File review of facility menu, it reveals facility offers resident breakfast, lunch, and dinner, ensuring the each meal is balanced with protein, carbohydrate, vegetables, and fats. Fruits and vegetables are available daily for residents in care. Based on information obtained, the allegation is unfounded. The complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 59-AS-20260220130912

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang conducted unannounced case management visit. LPA met with staff who contacted Administrator who arrived to the facility shortly afterwards. LPA explained the purpose of the visit. This visit is to deliver in-person of ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY. Facility understands this is an Immediate Exclusion and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. The Department was informed S1 has not worked at the facility since the time of the incident. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Dec 8, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the previously discussed incident that occurred on January 28, 2025. LPA met with Administrator and explained the purpose of the visit. Today's visit, LPA conducted a file review for S1. Additionally, LPA gathered a copy of S1's file along with staff training. Administrator was informed this matter remains under review by the Department. No deficiencies cited. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Required - 1 Year

On June 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Licensee/Administrator and explained the purpose of the visit. Today's census is 37 residents with zero (0) residents on hospice. Facility is compliance to license. LPA and Licensee conducted a tour of the interior of the facility. Areas toured included but not limited to: six (6) residents room, dining room, activity room, laundry room, shower room, kitchen and the common areas. LPA observed kitchen to be restricted to staff only. LPA was informed that if cook is not present then door will be locked for remainder of time. LPA observed present of two days of perishable and seven days of nonperishable foods. LPA was informed that day of visit, the freezer stopped working. Licensee is actively working on its repairs. LPA observed facility to have ample supply of linens, and hand sanitizers throughout the facility. LPA observed residents room to be free of sharps, toxins and medications. LPA was informed that medications are centrally stored unless stated otherwise by physician order and/or physician's report. File review was conducted for seven (7) resident records and five (5) personnel records. LPA observed resident records to have the required documents. LPA advised Licensee that all documents for each residents should be filed together. LPA observed staff files to be complete. LPA reminded Licensee that all staff are to have their initial 40 hours of training then follow with 20 hours of annual training. Staff who are administering medications are to have additional 24 initial hours of self-administration medication training. Please continue on LIC 809-C.the state’s words, verbatim · CDSS document, Jun 5, 2025

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On May 22, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit. LPA met with Licensee and explained the purpose of the visit. Today's visit, LPA and Licensee discussed that current Administrator has recently resigned. Licensee informed LPA a new Administrator is in the process of hiring, possibly effective June 2025. Licensee has an active Administrator Certificate which she will be interim Administrator for the time being. At this time, LPA is requesting a copy of Licensee's and potential new Administrator Certificate. No deficiencies cited. Exit interview, and a copy of report was provided.the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Due to lack of supervision, resident assaulted another resident

On April 11, 2025, Licensing Program Analsyt (LPA) Cassie Yang arrived unannounced at the facility to investigate the allegation of the complaint listed above. LPA met with medication technican and Assistant Administrator and explained the purpose of the visit. Today's investigation, LPA conducted extensive file reviews and interviews. Result of investigation is as follow on LIC 9099-C. Unfounded LIC 9099-C Allegation: Due to lack of supervision, resident assaulted another resident. The Department conducted interviews and file reviews. Based on file review of R1's care plan revealed R1 calls ombudsman for issues and needs outlet for complaints. R1's medical assessment indicated R1 is non-ambulatory physically and mentally with active problem of schizo affective disorder. File review of communication log revealed on March 26, 2025 R1 was observed to have a large upper arm bruising and will be going to the emergency room for evaluation. File review revealed on March 28, 2025 was when the alleged altercation occurred which R1 reported to S1. Interview conducted with S1 revealed S1 conducted an investigation and found that R2 "touched" R1's hand but did not hit R1. S1 stated R1 was satisfied with the response. On March 29, 2025, R1 then went to the emergency room to evaluate further new bruising on R1's chest area. Interview conducted with Assistant Administrator revealed there are at least two caregivers and one medication technican for AM and PM shift, and one staff for NOC shift. Assistant Administrator stated R1 takes Warfarin which causes usual bruises, R1 has the tendency of not fully speaking the truth as R1 has the diagnosis of schizo affective disorder. Interview with Assistant Administrator revealed R2 does not have a history of physical aggression to staff and residents in care. Based on information obtained, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 59-AS-20250401103006

Type of visit: Case Management - Deficiencies

On March 11, 2025, Licensing Program Analysts (LPAs) Cassie Yang and Kerry Hiratsuka arrived unannounced at the facility to conduct a case management visit regarding a deficiency observed. LPAs met with Administrator and explained the purpose of the visit. During today's visit, LPAs and Administrator discussed the incident that occurred on January 28, 2025. Based on file review, LPAs observed that S1 is not fingerprint cleared as a criminal record exemption is needed. File review of Guardian website revealed S1's fingerprint clearance is "in process" since November 25, 2024. Administrator stated S1 was working at the facility for two to three months prior the incident. S1 is not working at the facility at this time until cleared for exemption. Please see LIC 809-D. Civil penalty was assessed. Exit interview and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Mar 12, 2025

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations This requirement is not met as evidenced by: Based on file review, Licensee did not comply to section cited above as S1 was working at the facility when S1 did not obtained an exemption to work at the facility, which poses an immediate risk for residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: S1 is no longer working at the facility until cleared for exemption. Licensee is to submit a statement of compliance that all staff cannot work at the facility until Licensee obtained proof of clearance and/or exemption. POC is due March 13, 2025.

Type of visit: Case Management - Incident

On January 31, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with med-tech and explained the purpose of the visit. Additionally, LPA spoke with Administrator on the phone to inform Administrator of LPA's purpose. Incident report revealed that on January 23, 2025, S1 observed S2 asking R1 who is the current president, how many pills did R1 take. When R1 responded "I don't know", it was observed that S2 responded "you don't know anything, you have dementia." LPA and Administrator discussed the following incident. Administrator stated when it was reported to the Administrative Office, S2 has then been removed from the schedule and no longer works at the facility. Administrator stated the incident was self reported and corrective actions were taken immediately. As a result of the reported behavior of S2, deficiencies was cited. LPA explained that although facility took appropriate actions, since the incident did occurred at the facility, it was a violation against personal rights. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Feb 28, 2025

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as R1 was not treated with dignity and respect by S2 which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: S2 is no longer working at the facility. Licensee is to conduct an Elder Abuse training for all staff. Proof of training along with name of attendees are due to LPA Yang via fax or email by February 28, 2025.

Type of visit: Case Management - Incident

On January 31, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with med-tech and explained the purpose of the visit. Additionally, LPA spoke with Administrator on the phone to inform Administrator of LPA's purpose. Incident report revealed that on January 28, 2025, it was reported to the Administrative Office by S1 that S2 had obtained a photo of R1's credit card and purchased shoes online with R1's credit card information. S1 had returned the shoes and provided Administrator the refund to return to R1. LPA and Administrator discussed the following incident. Administrator stated S1 noticed that S2 had new shoes and when asked how did S2 afford them. S2 stated S2 took a photo of R1's credit card information and made purchases. Administrator informed LPA that S2 was terminated from the facility due to performance issues, prior to the awareness the financial abuse. Administrator stated she took immediate actions and made a police report and additionally, worked with R1's payee services to get the credit card successfully canceled. Administrator stated the shoe refund has not been given to R1 yet as R1 is currently out of the facility. As a result of the reported behavior of S2, deficiencies was cited. LPA explained that although facility took appropriate actions, since the incident did occurred at the facility, it was a violation against personal rights. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Feb 28, 2025

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... (8) To be free from neglect, financial exploitation... This requirement is not met as evidenced by: Based on file review, Licensee did not comply as incident report revealed S2 obatined R1's credit card information and purchased shoes, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: S2 is no longer working at the facility. Licensee is to conduct an Elder Abuse training for all staff. Proof of training along with name of attendees are due to LPA Yang via fax or email by February 28, 2025.

Type of visit: Case Management - Incident

On September 25, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced for a Case Management visit. LPA met with Sita, executive director, and informed her the reason for the visit. On August 8, 2024, Sita admitted a resident that came from a skilled nursing facility. That resident came to the facility with medication (narcotics). A second medication was mailed to the facility as well August 7. On August 31, 2024, Sita found medications outside the medication room, which was missing 30 pills out of 60 pills. Sita conducted an investigation and discovered a staff that had been employed with her for 4 years knew the most about the medication and signed for them when they arrived, but did not log them in. The next day 30 of those pills were missing. Sita terminated the staff's employment due to not following proper procedures and not reporting the incident to her when It happened. Sita filed a police report with Sacramento County Police. LPA reviewed the report. No citations were issued. An exit interview was conducted and a copy of this report was given to Sita.the state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Required - 1 Year

On May 15, 2024, at 8:57 am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Sita Vadarevu, Licensee, who assisted LPA in today’s inspection. The Administrator certificate expires 7/25/25. The current census is 32. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 75 degrees F which is within range. Sita and LPA completed the inspection tool with no issues or concerns. The facility is a one-story facility. Living rooms, dining room, and areas designated for resident use were toured. LPA inspected the interior and the exterior of the facility. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. There are 24 rooms. LPA inspected several rooms. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. To continue see 809.... Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible. There’s a centralized storage area for resident’s medication. The facility Medication Administration Record and the dispensing log was reviewed. No issues of concern. First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguishers are maintained and ready for emergency use. LPA reviewed 6 resident files and 3 staff files. Resident files are current and had all the required documents. Staff files reviewed revealed facility is conducting the required training, have Criminal Record Clearances and updated Emergency Contacts. LPA interviewed residents for the infectious Control questionnaire. The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than June 15,2024. Per California Code of Regulations, Title 22, no citations were issued. An exit interview was conducted and a copy of this report was given to Sita.the state’s words, verbatim · CDSS document, May 15, 2024