306005603-1-20-2023-22-AS-AORZ-CP4NHJ-20230216092842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:40:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2023 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230112164247

FACILITY NAME:	CITRUS HILLS ASSISTED LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR:	JUAN JORGE POEMAPE-DIAZ		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	95	CENSUS: 78	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Operations Manager - Itzayana Barba Aguirre		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are violating House Rules by smoking marijuana and cigarettes inside of the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Patricia Velazquez conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the allegation. LPAs Ramirez and Velazquez were allowed entry into the facility and initially met with Medication Technician Sarah Tanner and explained the purpose of the visit. Operations Manager Itzayana Barba Aguirre arrived later to assist with the visit.

On today's visit LPAs Ramirez and Velazquez conducted interviews with residents and staff. LPAs also reviewed and obtained copies of facility, resident and staff records. During the course of the investigation the following was revealed: LPAs Ramirez and Velazquez conducted interviews with residents and staff. During the resident interviews LPAs observed a cigarette on a small table next to Resident (R) #1's bed that was lit and smoke emanating from the cigarette. As LPAs were entering R1's room, R1 immediately disposed of his cigarette in the trash can which LPAs observed. LPAs observed a strong smoke odor present in the room

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 22-AS-20230112164247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CITRUS HILLS ASSISTED LIVING	FACILITY NUMBER: 306005603
	VISIT DATE: 01/20/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

of several residents. R2 confirmed smoking marijuana in their room twice a day. 8 of 10 individuals interviewed confirmed they either smoke inside the facility or have observed other residents smoke inside of the facility. Records reviewed included resident Admission Agreement and Resident Handbook and House Rules. Page 1 of Resident Handbook and House Rules states: "We are a SMOKE FREE building. Smoking is not permitted inside the building under any circumstances."

Based on the observations of LPAs Ramirez and Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Residents are violating House Rules by smoking marijuana and cigarettes inside of the facility is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Operations Manager Itzayana Barba Aguirre and a copy of this report along with the LIC 811, LIC 9098 and the Appeal Rights were provided at the time of this visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20230112164247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CITRUS HILLS ASSISTED LIVING	FACILITY NUMBER: 306005603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/14/2023 Section Cited CCR 87203	1 2 3 4 5 6 7	Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidence by: LPAs observed evidence of residents smoking cigarettes and marijuana in their	1 2 3 4 5 6 7	On 01/27/23 the Plan of Correction was submitted to LPA Alvaro Ramirez, Jr. The deficiency was cleared on that date. Plan of Correction letter was provided at the time of this visit.
	8 9 10 11 12 13 14	rooms and there are residents in the facility that utilize oxygen. This poses an immediate risk to the health and safety of residents in care. This is an amended report. *$500 Civil Penalty Assesed.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4