306005603-7-6-2023-22-AS-AORZ-CTHU55-20230707151611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:32:49 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
05/15/2023 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230515083103

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: 84	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Itzayana Barba Aguirre-Operations Manager		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not ensure that resident received prescribed medication while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 05/15/23. LPA was greeted and granted entry into the facility and met with Operations Manager (OM) Itzayana Barba Aguirre. LPA explained the reason for the visit.

This agency has investigated the complaint alleging that facility staff did not ensure that resident received prescribed medication while in care. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Eight of ten individuals interviewed reported that medications are always given and on time. As for the remaining two individuals, one individual confirmed the allegation and the other reported that they do not distribute medication. During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 11/21/22 for Resident 1 (R1). Per Physician Report R1 is not able to administer own prescription medications.

Continued on LIC812C...

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: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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-20230515083103

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: 07/06/2023

NARRATIVE

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It was reported via interviews that R1 had a drinking problem and that R1 was not present for their medication at the time the evening medications were distributed. Per OM, R1’s prescription did not include specific instructions such as not being able to take the pills after drinking alcohol. Despite their concerns about mixing the medication with alcohol, no proof could be found that the facility requested written instructions from R1’s physician regarding the resident mixing alcohol and medication. Per interviews conducted, staff admitted not administering R1’s medications when arriving to the facility late if intoxicated. Records reviewed by LPA Ramirez included the Medication Administration Record (MAR) dated April 2023 and May 2023 for R1. Per MAR for R1 the evening medications were either marked as Administered, Drug Refused and/or Absent from Facility. During the course of the interviews OM stated that R1 did not sign out of the facility during the times their MAR was marked as Absent from the facility and that R1’s Physician was verbally notified. During the investigation LPA reviewed documents including the Physician Order/Medication Review Report dated 12/15/2022 for R1. R1’s Physician Order/Medication Review does not include instruction and/or warnings regarding the prescribed medications.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility staff did not ensure that resident received prescribed medication while in care 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 OM Barba and a copy of this report along with 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: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230515083103

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: 07/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/07/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the	1 2 3 4 5 6 7	Licensee to conduct an in-house training on passing medication as ordered by the physician. Licensee to submit written proof to LPA by POC due date.
	8 9 10 11 12 13 14	medication is given according to the physician's directions. This requirement is not met as evidence by: staff admitted not administering R1’s medications when arriving to the facility late if intoxicated; however, no proof could be found that the facility requested written instructions from R1’s physician regarding the resident mixing alcohol and medication.	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: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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