306005603-10-29-2021-22-AS-RQUZ-C89T2E-20211029142038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 10/29/2021
Date Signed: 10/29/2021 02:20:42 PM

COMPREHENSIVE INSPECTION

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 LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR:	TANJA OLANO		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	95	CENSUS: 45	DATE:	10/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Kathleen Olson, Market Leader and Juan Jorge Poemape Diaz, Operations Manager		TIME COMPLETED:	02:35 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Front desk Receptionist and Business Office Manager Lynn Voung. LPA Quiroz met with Kathleen Olson, Market Leader (ML) and Juan Jorge Poemape Diaz, Operations Manager (OM) and explained the nature of the visit. This facility is licensed to provide services to residents age range 60 and over. Approved for 95 Non-Ambulatory residents, of which 12 may be bedridden and has an approved hospice waiver for 20 residents.

(ML) Kathleen Olson indicated AD Tanja Olano is no longer with the company, and indicated Juan Jorge Poemape Diaz is current Operations Manager (OM) . (OM) Juan Jorge Poemape Diaz indicated he already took the Administrator course, and currently waiting for Administrator Certificate. (ML) Kathleen Olson indicated (OM) will resume (OM) position effective November 1, 2021 and aware how to associate (OM) Poemape Diaz as Operations Manager and provide CCL with copy of Adminsitrator Certificate upon receiving it.

On or about 12:38pm LPA Quiroz along with (ML) Kathleen Olson toured the inside and outside of facility. All staff working at facility were observed to be wearing face masks upon arrival to facility. There are forty five (45) residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed residents eating their lunch in dining-room, while others ate lunch in their bedrooms by personal choice. Residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary with all required components. LPA Quiroz observed a check in station in the main entry of the facility; however was not asked to be properly screened upon facility entrance. (SEE LIC 9102)

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies stored in storage room on second floor. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 306005603
	VISIT DATE: 10/29/2021

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CONTINUED....

LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment in court yard on first floor and second floor balcony. Facility has completed the LIC 808 Mitigation plan, which was approved by LPA Micah Martinez on 3/12/2021.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. Technical Violation LIC 9102 provided during today's visit.

This report was reviewed with (ML) Kathleen Olson, and a copy of this report and LIC 9102 were provided to (ML) Kathleen Olson at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC809 (FAS) - (06/04)

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