CITRUS HEIGHTS TERRACE

Official classification

Type A

Official code

1569.699(5)

Regulation authority

HSC

What the official deficiency says

§1569.699 Exit doors; egress-control devices of time-delay type; fences (a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements: (5) Actuation of the panic bar or other door-latching hardware shall activate an audible signal at the door. This requirement is not met as evidenced by: Based on interview with the Interim Administrator and Resident Care Coordinator, the Licensee did not ensure that the egress door alarm sounded on Monday, August 10, 2026 (5:09 pm) when (R1) was able to exit from the community, unassisted, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator already conducted staff training with the " pm " shift on the August 10, 2026. Training to be scheduled for the " am " and " NOC " shifts - will conduct training at their cross-over within a week, or by 8/20/2026. Maintenance already increased the time from (15) seconds to (30) seconds until the egress door opens after the alarm is sounded. Additionally, maintenance will possibly change a part in the magnetic box if it's determined to be related to the alarm not sounding. The facility has started the process of placing a staff person at the concierge from 5-8 pm. Lastly, the facility is in discussions about adding an interior security door that clients would have to go through before they are able to reach the egress door. The facility agrees to provide any updates/documentation related to these follow up actions, to the Department, by August 27, 2026.

Deadline recorded: Aug 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(6)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by: Based on documentation reviewed and an interview conducted, the Licensee did not ensure that resident (R1) was unable to exit the facility, unassisted, on May 26, 2026 (10:53 am), which posed an immediate health and safety risk to residents in care. (R1) was returned to the facility around 12:14 pm, with no injuries noted.

Official plan of correction

Licensee/Administrator agree to conduct training on the timing of the egress door, specific to when the alarm sounds and when the door unlocks. The Administrator will hold an elopement drill today (pm shift) to note which caregivers attended to the alarms with urgency and who did not, and note the reason they did not and follow up with disciplinary action. (R1's) care plan was updated with more details of care needed to address the elopement risk. The facilitly will consider obtaining another type of bracelet/anklet that (R1) cannot remove easily. The facility will continue to communicate (R1's) primary care physician. Documentation of training due to CCLD by tomorrow, 5/29/26 (COB).

Deadline recorded: May 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(6)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement is not met as evidenced by: Based on documentation reviewed and an interview conducted, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on 4/19/2026 (5:05 pm approximatey), which posed an immediate health and safety risk to residents in care. Resident was returned to the facility, uninjured, 20 minutes later, at approximately 5:25 pm.

Official plan of correction

Staff training on Delayed Egress Doors and the Wander Guard System was conducted by the RCC on April 21, 2026. LPA obtained a copy of the training agenda/attendees. Additionally, daily radio checks are completed as well as reminders during stand-up (9:15 am) and at cross over meetings (3:00 pm). The facility will obtain an updated Physician's Report to accurately reflect (R1) being at risk for elopement and unsafe wandering. (R1) initially wore a Wander Guard bracelet on their wrist until/around February 17, 2026, when it was replaced with a Wander Guard anklet. (Consent form on file- signed by (R1) and their responsible person). *THERE IS NO FURTHER ACTION NEEDED- POC CLEARED ON APRIL 22, 2026. *

Deadline recorded: Apr 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(d)(1)

Regulation authority

CCR

What the official deficiency says

(d) Residents may have access to items specified in subsection (c) for personal use unless there is documentation as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. (1) The licensee shall implement reasonable interventions in order to ensure that access to the items specified in subsection (c) does not pose a hazard to other residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in a closet conatining hazardous items was left unlocked and unattended which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/14/2026 Plan of Correction Licensee will submit the housekeeping training plan for ensuring, verifing and checking that items to be secured house supplies used and accessed are done so and proof that all staff reviewed the procedures by the POC date of 4/14/26

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 resident (R1) received timely medical attention, on 8/28/24, after having an unwitnessed fall that morning, as (R1) was not sent out to the hospital until 19:28 hours, and had displayed a change in baseline behavior with her mobility, which posed an immediate health and safety risk to residents in care. (R1) was diagnosed with a left hip fracture after being sent to the hospital on the evening of 8/28/24.

Official plan of correction

Licensee/Administrator agree to provide staff with training on fall protcols and when to send a resident out for medical attention. Staff training to be completed and documentation provided to the Department by 11/4/24. Admin to advise LPA by 10/22/24 of the training agenda. An immediate civil penalty is being assessed today for $500.00.

Deadline recorded: Oct 22, 2024. A deadline is not proof that correction was completed.

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 was not met as evidenced by: Based on interview conducted and documentation reviewed, the Licensee did not ensure that resident (R1) was not able to exit the facility, unassisted, on 4/6/24 (5:10 pm approximatey), which posed an immediate health and safety risk to residents in care. Resident was returned to the facility, uninjured, 20 minutes later, at approximately 5:35 pm.

Official plan of correction

The Licensee/Administrator immediately trained all staff on delayed egress, elopment procedures and re-arming a delayed egress lock after each use. In addition, an auditory alarm as well ass a strobe system will be installed in another location in the faciltiy to assist staff hear when an alarm is activated. Documentation of training to be sent to CCLD by 4/17/24. Photo documentation to be provided to CCLD showing that an additional auditory alarm and stobe lights have been installed. Due by 4/30/24.

Deadline recorded: Apr 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that staff (S1) had completed the required training related to Dementia care, which posed an immediate health and safety risk to residents in care.

Official plan of correction

(S1) is no longer employed at the facility as of February 2024. Licensee/Administrator to ensure that all care staff have completed the required initial and/or continuing training hours. LPA to review training documentation during the upcoming annual by 4/30/24.

Deadline recorded: Mar 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Basd on documentation review, the Licensee did not ensure that item #25- Medication Safety, (listed in the Resident Handbook) which reads: " Medications will be Centrally Stored and monitored by Community Staff " , was followed, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator has already requested to consolidate (R1's) current pharmacy into another pharmacy that will deliver directly to the facility. Administrator will attempt to consolidate all medication distribution into one pharmacy provider. Documentation to be provided by 10/18/23 of any consolidations .

Deadline recorded: Oct 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(5)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the prior Administrator included accurate information only on the LIC624 submitted to the Department on/around 4/27/23 for the incident ocurring on 4/26/23 regarding (R1) going to the hospital, which posed a potential health and safety risk to residents in care.

Official plan of correction

The Administrator who submitted the LIC624 is no longer employed at the facility. The current Administrator reviews all LIC624's prior to submission and will ensure their accuracy. There is no further POC action needed on this one.

Deadline recorded: Oct 18, 2023. A deadline is not proof that correction was completed.