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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 04/19/2021
Date Signed: 04/19/2021 02:57:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CITRUS HILLS ASSISTED LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR:TANJA OLANOFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:95CENSUS: 52DATE:
04/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Tanja Olano, AdministratorTIME COMPLETED:
12:10 PM
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On today's date Licensing Program Analysts (LPA) Rosie Quiroz contacted the facility via telephone to conduct a Case Management visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPA Quiroz spoke with Administrator Tanja Olano, and discussed the purpose of the visit. The purpose of this Case Management visit was to follow-up on two different self reporting special incident report (SIR) received in the Orange County Regional Office on 4/16/2021 regarding Resident (R1) and (R2).

On or about 11:18am, LPA Quiroz along with Administrator Olano conducted a virtual tour utilizing Face-Time of the interior of the facility. LPA Quiroz also conducted interviews with Administrator and medication technician on site. LPA Quiroz also requested copies of pertinent records from the files of (R1) and (R2).

There were no deficiencies issued during this Case Management visit. An exit phone interview was conducted with Administrator Olano. This report will be sent via email to Administrator Olano who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Olano agrees to return the sign report.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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