306005603-1-12-2023-22-AS-SSAS-CN9NR4-20230120094052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:34:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200506165246

FACILITY NAME:	CITRUS HILLS ASSISTED LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR:	JOHNSON, SHANNON		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	95	CENSUS: 75	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Itzayana Barba Aguirre - Operations Manager		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Facility does not provide a safe environment for resident
Lack of supervision resulted in resident wandering into another resident's room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and met with Operations Manager Itzayana Barba Aguirre and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with staff. During the course of the investigation, LPAs Ruth Martinez, Rosie Quiroz and Patricia Velazquez conducted interviews with the complainant, residents, and staff. LPAs Quiroz and Velazquez obtained facility, resident, and staff records. The records reviewed included Resident Admission Records, Physician's Reports, Service Plans, an Unusual Incident Report for Resident (R) #1 for an incident that occurred on May 31, 2020, Medication Review Reports, Resident Progress Notes and R1's Death Report. Regarding the allegation: Facility does not provide a safe environment for resident, during the course of the investigation the following was revealed: eight of eight individuals interviewed provided

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200506165246

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/12/2023

NARRATIVE

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conflicting statements and could not corroborate the allegation. Regarding the allegation: Lack of supervision resulted in resident wandering into another resident's room, eight of eight individuals interviewed provided conflicting statements and could not corroborate the allegation. A family member of R1 stated the facility provided a safe environment for residents in care as well as adequate care and supervision to meet the needs of R1 and the other residents.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegations: Facility does not provide a safe environment for resident and Lack of supervision resulted in resident wandering into another resident's room are deemed UNSUBSTANTIATED.

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

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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