306005603-5-11-2023-22-AS-SSAS-CRRT28-20230512142017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:25:13 PM

Unsubstantiated

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
04/26/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230426090325

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: 88	DATE:	05/11/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Itzayana Barba, Executive Director		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility failed to meet reporting requirements

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above.

On April 28, 2023, LPA conducted an initial investigation visit at the facility with the assistance of Citlalli Galeana, Wellness Coordinator. LPA obtained the facility's current census of 88 residents, the facility roster on an updated form LIC500, internal incident reports and Special Incident Reports transmitted to the Department for the months of March and April 2023, as well as the physician reports, service plans, needs assessments and plan of care print-outs for five current residents. Two staff interviews and three resident interviews were either conducted or attempted during the visit.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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-20230426090325

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: 05/11/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility failed to meet reporting requirements, the following has been concluded: Per facility procedure, fall incidents and medical emergencies are typically reported when they involve paramedics being called via 911 and/or a transfer of the resident to their hospital of choice for evaluation and treatment, as was confirmed by reviewed incident reports communicated to the Department SIR fax line, including an incident that occurred on April 18, 2023 requiring a hospitalization for resident R1. A subsequent report for an incident dated April 20, 2023 for the same resident, not resulting in a hospitalization was also provided by facility staff during the visit. Other falls evidenced by resident interviews were not reported after it was assessed by facility staff that there were no serious implications for the welfare, safety or health of the resident involved.

The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred.

A Technical Assistance Advisory Note is issued regarding Reporting Requirements.

An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC9099 (FAS) - (06/04)

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