Dementia care
Cited in 4 reports, with 4 deficiencies in total.
CITRUS HEIGHTS TERRACE
7952 OLD AUBURN ROAD, Citrus Heights CA 95610
49 bedsLatest official report Aug 25, 2026Licensed
Additional info
- Telephone
- (916) 727-4400
- Licensee
- CITRUS HEIGHTS TERRACE
- Administrator
- MAGDA LUIS
- Contact
- MAGDA LUIS
- License first date
- Apr 13, 2000
- License effective date
- Apr 13, 2000
- District office
- SACRAMENTO NORTH ASC · (916) 263-4700
- Regional office
- 59
- Clients served
- 935 - ELDERLY
Summary
The available records show 23 Type A and 13 Type B deficiencies for this facility.
- Most recent inspection
- Aug 25, 2026
- Most recent deficiency
- Aug 13, 2026
1 later report, on Aug 25, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 13 Sacramento County facilities licensed for 16 to 49 beds, except where too few exist to state one — those come from facilities with 7 or more beds.
In the available public five-year record, CCLD published 103 reports for this facility: 48 inspections, 51 complaint investigations, and 4 licensing or administrative records.
Those records contain 23 Type A and 13 Type B deficiencies.
2 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 48
- Recorded deficiencies
- 36
- Type A deficiencies
- 23
- Type B deficiencies
- 13
- Substantiated complaints
- 17
- Repeated topics
- 9
More than the typical 10
16 in the last 12 months
Well above the typical 8
5 in the last 12 months
Well above the typical 4
4 in the last 12 months
Well above the typical 4
1 in the last 12 months
Well above the typical 2
1 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Medical and dental care
Cited in 4 reports, with 4 deficiencies in total.
Resident rights
Cited in 4 reports, with 4 deficiencies in total.
Staffing, personnel, and training
Cited in 4 reports, with 4 deficiencies in total.
Basic services and supervision
Cited in 3 reports, with 3 deficiencies in total.
Facility condition and maintenance
Cited in 2 reports, with 3 deficiencies in total.
Admission, assessment, and eviction
Cited in 2 reports, with 2 deficiencies in total.
Incident reporting
Cited in 2 reports, with 2 deficiencies in total.
Medication handling and storage
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Jan 13, 2026 · Control 59-AS-20251014152318
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff provided the necessary interventions on August 5, 2025, starting at around 11:00 am, when (R1) was observed to be running throughout the facility, until 4:45 pm, when (R1) fell near the dining room and sustained a nasal bone fracture and laceration on the nose and lips,, requiring stitches in the emergency room, which posed an immediate health and safety risk to residents in care.
Official plan of correction
The Licensee/Administrator agree to conduct in-service training with all staff to discuss following protocols when there is change of condition, including contacting the resident's primary care provider for direction, requesting a UTI analysis. Training agenda/date due by tomorrow, November 19, 2025- additional time can be allowed for the training itself (2 weeks).
Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 19, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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: 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.
Official plan of correction
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. 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.
Deadline recorded: Aug 5, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 5, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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: Based on interviews conducted and documenation reviewed, the Licensee did not ensure that adequate supervision was provided to (R2) and (R1), prior to March 30, 2025 (9:30 am) when (R2) entered (R1's) room and attacked (R1) while (R1) was resting, which poses an immediate health and safety risk to residents in care. (R2's) care plan, (dated 7/1/2024), notes that resident requires " maximum assist " with staff monitoring behavioral expressions and resident has had " some expressions that Admin is monitoring closely " .
Official plan of correction
Licensee/Administrator began 1:1 supervision with (R2) following the incident on 3/30/2025 but (R2) moved out on 3/31/25. The Administrator created a policy (on 4/8/2025) addresing when 1:1 staff should be implemented for a resident with behaviors or for other reasons. Training to be conducted in August for all staff, including newer staff, on August 10, 2025. A CIVIL PENALTY IS BEING ISSUED IN THE AMOUNT OF $1,000.00 ALSO.
Deadline recorded: Jul 30, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 30, 2025
Correction not verified in available records
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)(1)(C)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to: (C) Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement is not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that resident (R2's) care plan was updated following resident showing a change in condition with behaviors/behavioral expressions documented back to October 2024 through March 2025, which posed a potential health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to continue to review each resident's care plan after a behavioral expression, or fall, and update the " Behavioral Expresssion Appraisal and Plan " or " Post Fall Assesment Plan " as needed. A Post-Fall Assessment is completed when the LIC624 is completed. (R3) moved out of the community on/around March 31, 2025. Currently there are no residents with aggressive behaviors.
Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 12, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observations and interviews conducted, the Licensee did not ensure that carpet areas were maintained in a clean, sanitary and odorless condition, on/around September 2024- October 2024, which posed a potential health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator are planning to schedule professional carpet cleaning every 2.5 month or sooner, if needed, and to spot clean frequently. The facility recently changed to a diffrerent company which appears to be cleaning the carpet more throughly. Documentation of scheduled cleanings to be provided to the Department by 2/20/25. Also, any carpet tears will be repaired soon.
Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 20, 2025
Correction not verified in available records
Complaint
Allegations2 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited · investigated over 2 visits
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
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: 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.
Official plan of correction
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.
Deadline recorded: Feb 14, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 14, 2025
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jan 31, 2025 · Control 59-AS-20241014152140
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff frequently monitored resident (R1)'s condition while outside on the patio, on the afternoon of 9/22/24, to prevent (R1) from suffering a heat stroke, when temperatures reached 91*F, which posed an immediate health and safety risk to residents in care. Resident was sent to the emergency room at 1545 approximately and diagnosed with an altered state of consciousness and heat stroke.
Official plan of correction
Licensee/Administrator conducted staff training on 9/24/24, with the " am " shift regarding checking on residents at least every hour and offering beverages to prevent dehydration. Documentation was reviewed showing staff provided 30 minute checks on (R1) the following day, on 9/23/24. New staff will receive training on outside monitoring of residents. The Administrator stated on 9/24/24 the camera monitor from her office will be moved to the front desk area and a bigger camera monitor will be installed in her office and in the dining rooms. Also staff will be asked to check residents outside, every 10 minutes. *On 12/23/24, LPA observed the camera in the Administrator's office showed certain areas of the patio but not the seating area at this time.
Deadline recorded: Dec 24, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 24, 2024
Correction not verified in available records
Complaint
Allegations3 substantiated · 1 unsubstantiated · 0 unfounded · 3 cited · investigated over 2 visits
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87265(b)(3)
- Regulation authority
- CCR
What the official deficiency says
87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was provided with regular incontinent care to ensure she was kept clean and dry, on multiple occasions, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/administrator agree to provide follow up staff training on which residents require more frequent incontinent checks. Consider documentating when 2 hourly checks are made and when resident is changed. Communication with families to also be part of the training. Training agenda due to LPA by 10/11/24 Completed training documentation by 10/24/24.
Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 11, 2024
Correction not verified in available records
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(d)
- Regulation authority
- CCR
What the official deficiency says
87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received regular applications of lotion and cream, as ordered, for eczema, and assistance with oral hygiene care, on multiple occasions, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/administrator to to provide follow up staff training on ensuring creams/lotions are applied as needed and oral hygiene care is regularly provided. Communication with families to also be part of the training. Training due to LPA by 10/24/24. Completed training documentation by 10/24/24.
Deadline recorded: Oct 10, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 10, 2024
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Oct 10, 2024 · Control 59-AS-20240605141044
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the Licensee did not ensure that resident (R1) received eye drops as ordered on 5/11/24 (evening /bedtime doses) and on 6/22/24 (evening dose), which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to conduct staff training on medication administration involving an outside care provider, refill protocols. Administrator to discuss the training with the company nurse who will be in the building tomorrow, 10/9/24. Administrator will follow up with Dept to confirm a training day for staff. LPA stated 2 weeks can be given for staff training, or by 10/22/24.
Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 9, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 2 unsubstantiated · 0 unfounded · 2 cited · investigated over 2 visits
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(2)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure resident (R1) was administered PRN Loperamide 2 mg (Imodium), as prescribed, on 12/9/23 (2:00 am) and following diarrhea, which posed a potential health and safety risk to residents in care. (R1) was sent to the emergency room for further evaluation.
Official plan of correction
Licensee/Administrator have already completed staff in-service training for PRN medications and documentation on the PRN log and MAR. Documentation of training completed in February 2024 and later by 3/14.24.
Deadline recorded: Mar 14, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 14, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 1 unsubstantiated · 1 unfounded · 1 cited · investigated over 2 visits
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that resident (R1) did not miss a dosage of Olanzapine on/around August 24-25, 2023, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator will inquire if they can contract with a local pharamcy regarding obtaining a private pay emergency supply, if the family member doesn't pick up the medications timely. All Med-Tech staff were re-trained or in the process of being retrained, on thorough documentation on the MAR and LIC622 and documenting attempts to contact family members when a refill is needed. Documentation to be provided by 2/1/24 for training and by 2/8/24 for the local pharmacy.
Deadline recorded: Feb 1, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 1, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1
- Regulation authority
- CCR
What the official deficiency says
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: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement isn not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1) was allowed to accept a phone call from a family member on 1/20/24 at approximately 8:48 pm, which posed a potential personal rights violation to residents in care. Resident was very agitated and staff didn't feel she was emotionally able to take the call at that time.
Official plan of correction
Licensee/Administrator already received clarification because of the situation and phone calls will be allowed between 9:00 am and 9:00 pm, provided the resident is awake and available to talk. POC is cleared today, 1/25/24.
Deadline recorded: Feb 8, 2024. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn Jan 25, 2024
Plan of correction recorded
Correction deadline recordedDeadline Feb 8, 2024
Complaint
Part of the complaint whose outcome is recorded on Jan 30, 2024 · Control 59-AS-20240102161217
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Mar 13, 2024 · Control 59-AS-20231226105149
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87413(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87413 Personnel - Operations. (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Based on interviews conducted and text messages reviewed, the Licensee did not ensure that there was a Med-Tech staff or other staff on duty on 12/24/23, from approximately 10:54 pm to 11:50 pm, that was able to administer PRN medication for pain to (R1), which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to immediately schedule a Med-Tech staff or other staff that is trained to administer medications, for all shifts, effective 12/28/23. Administrator confirmed with RCC on 12/28/23 that staff (S1) is scheduled for PM and NOC shift from 12/28/23-12/29/23 and other NOC shifts. Additionally, another Med-Tech was recently hired to work NOC shifts if needed. Documentation of Med-Tech schedule from 12/28/23 - 1/31/24 to be provided to the Department by 12/29/23. Admin will cover 1/27/24 and RCC will cover 1/19/24.
Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 29, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 5 unfounded
No deficiencies recorded in this reportComplaint
Allegations3 substantiated · 3 unsubstantiated · 1 unfounded · 3 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
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: Based on interviews and documentation reviewed, the Licensee did not ensure that (R2) and (R1) were provided with sufficient supervision, on 4/15/23, during the NOC shift, to prevent him from entering (R1's) room and laying naked on (R1) while she was in bed, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to conduct staff in-service training regarding sexual abuse and checking rooms, more regularly, throughout more shifts. Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.
Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 27, 2023
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not ensure that (R1) received prompt medical attention, following the incident with (R2) on 4/15/23, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to conduct an in-service training on when to call 9-1-1 and seek medical attention needed, Agenda to be received by 10/27/23- training documentation to be submitted by 11/9/23.
Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 27, 2023
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews conducted, the License did not ensure that (R1's) responsible person was provided with copies of incident reports when requested on/around May 2023, which poses a potential health and safety risk to residents in care.
Official plan of correction
Administrator agree to continue to submit LIC624's timely and to provide a copy to the responsible within (7) days of the incident. Administrator to discuss with Resident Care Coordinator and submit documentation to CCLD that this protocol has been discussed and will be regularly followed. Documentation to be submitted by 11/9/23 to CCLD. Administrator will attempt to contact responsible person of (R1) and send all LIC624's, as requested.
Deadline recorded: Nov 9, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 9, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 0 unsubstantiated · 4 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 3 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(3)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental Care.(c )(3)A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by records and interviews That found PRN use by residents are not consistently recorded as required. This posed a potential risk to residents.
Official plan of correction
Licensee will submit the procedures for administering and documenting resident PRN use and staff training of the procedures to CCL by the POC date of 11/9/23.
Deadline recorded: Nov 9, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 9, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations7 substantiated · 5 unsubstantiated · 0 unfounded · 5 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that the medication Galantamine, for (R1), was administered as ordered on/around April 2023 and that no medication went missing, which posed an immediate health and safety risk to residents in care. (R1) missed several days of this medication.
Official plan of correction
Licensee/Administrator agree to continue with staff training, pharmacy audits, and reviewing the documentation every week. Documentation to be provided by 10/2/23 of what has been completed so far.
Deadline recorded: Oct 2, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 2, 2023
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(8)
- Regulation authority
- CCR
What the official deficiency says
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: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that family members were notified that (R1) was sent to the hospital, and for what reasons, on 4/26/23, which posed a personal rights violation to residents in care.
Official plan of correction
Licensee/Administrator conducted staff training in the last month regarding emergency assistance protocols. Documentation to be sent by 10/13/23.
Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2023
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, the LIcensee did not ensure that all pull cord devices were in working order, including in (R1's) bathroom, from approximately Feb- May 2023, which posed a potential health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to continue check weekly with the Maintenance Director. All bathrooms and pull cords are being checked weekly. Documentation to be submitted by 10/13/23.
Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2023
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)(3)
- Regulation authority
- CCR
What the official deficiency says
Reg 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation on 5/12/23 and 9/26/23, the Licensee did not ensure that there were paper towels or cloth towels available for use in (R1's) bathroom, which posed a potential heatlh and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to discuss options regarding installing a paper towel roll holder or dispenser. Provide documentation of solution by 10/13/23.
Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2023
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evicenced by: Based on interviews conducted, the LIcensee did not ensure that (R1's) family was provided with all LIC624's since moving to the community after they were requested.
Official plan of correction
Licensee.Administrator agree to discus with RCC on this process and provide documentation of the protocols to be followed. Documentation due by 10/13/23.
Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 3 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the Licensee did not ensure that medications changes for resident (R1)faxed to the facility on 7/28/23 were updated timely in the system to be reflected on the MAR, which poses an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to submit a training plan to the Department by 8/10/23 regarding medication training, to include timely entering of medication orders in the system and correct documentation/initialing on the MAR. Documentation of completed staff training to be submited to the Department by 8/23/23 to include agenda and attendees.
Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 10, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 1 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documentation reviewed (LIC624 and medication documentation), the LIcensee did not ensure that resident (R1) was administered Hydrocodone (Norco) 325-5 mg table from 7/18/23-7/20/23), due to a bottle of the medication missing, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to conduct additional staff training on the 3-step process in logging narcotics for staff accountability. Documentation of staff training (agenda/attendees) due to the Department by 8/14/23.
Deadline recorded: Aug 14, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 14, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 5 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and record review on 6/28/23, the Licensee did not ensure that medications were administered as ordered for residents (R1 and R3), which posed an immediate health and safety risk to residents in care.
Official plan of correction
Licensee/Administrator agree to conduct staff training on medication management to include topics: Correct documentation by staff on the MAR and LIC622; how to log a new or refilled medication; importance of entering start date on the LIC622; process of calling timely for a refill Any other medication related topics Documentation to be provided to CCLD by 7/21/23 by email/fax of all Med-Tech staff. LPA observed documentation of completed training for " Medical Error Prevention " for (S2) on 7/17/23 and a new staff is in the process of completing.
Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.
Corrective action observedRecorded in report dated Jul 20, 2023
Plan of correction recorded
Correction deadline recordedDeadline Jul 31, 2023
Complaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(j)
- Regulation authority
- CCR
What the official deficiency says
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Based on interviews conducted and observation, the LIcensee did not ensure that the auditory device on the patio exit door was working effectively, on 6/29/2023 (7:30 pm approximately) , to alert staff that resident (R1) had exited the the building, which posed an immediate health and safety risk to residents in care.
Official plan of correction
Maintenance Director stated on 7/6/2023 that the batteries in all (3) exit doors without a delayed egress alarm were replaced following the incident (AWOL) on 6/29/2023. Administrator and Maintenance Director agreed to place a second working alarm on each exit door so it can be heard by staff and also conduct a staff elopement drill. Documentation of a second alarm being placed on the door to be provided to the CCLD by 7/7/2023. Documentation of staff training for elopment drill to be provided to CCLD by 7/21/2023. Administrator stated she would discuss additional possible solutions with the Regional Director, including installing an outside camera on each patio, updating the pager system to include alerts from exit doors, use a Wanderguard bracelet on any resident(s) that has wandering tendencies.
Deadline recorded: Jul 7, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 7, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportSource and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
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