306005603-5-4-2023-22-AS-AORZ-CTLMVM-20230710095657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:19:30 PM

Substantiated

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
04/26/2023 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230426173357

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: 90	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Yairell Garcia		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility did not ensure that resident received prescribed medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Health and Wellness Director Yairell Garcia and explained the reason for the visit. The investigation revealed the following. It was alleged that the facility did not have Resident 1's (R1) Hydrocodone-Acetaminophen oral tablet 5-325MG (PRN) refilled timely and R1 did not have the PRN medication from 4/17/23 until the morning of 4/20/23 even though they requested the medication. Staff interviewed reported that the medication was ordered, the pharmacy and doctor were contacted. Staff reported that it takes time for a medication order to process and the medication must be approved by the resident's physician before a prescription is filled. A review of R1's medication administration record for April 2023 shows that R1 did not take any Hydrocodone-Acetaminophen from 4/16/23 to 4/19/23. R1 has resided at the facility since February 2023. R1's service plan and admission agreement show R1's medication is managed by the facility. It is the facility's responsibility to ensure the resident has their medication and to administer the medication in accordance with doctor's orders. R1 could not get their requested medication from 4/17/23 to 4/19/23, all parties interviewed corroborate this information.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 3

Control Number 22-AS-20230426173357

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/05/2023 Section Cited CCR 87465(c((2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure all medications are given in accordance to doctor's orders at all times. Licensee to train med-tech staff on personal rights of residents and administration of PRN medications. Licensee to submit proof of training by to LPA by POC due date.
	8 9 10 11 12 13 14	based on record review and interviews the Licensee did not ensure the medication, Hydrocodone-Acetaminophen, for R1 was given according to physician's orders (PRN) from 4/17/23 to 4/19/23 when requested by R1. This poses an immediate risk to the health & safety of residents in care.	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: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230426173357

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: 05/04/2023

NARRATIVE

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Based on the evidence gathered through interviews and a review of records, the preponderance of evidence standard has been met, therefore the following allegation, facility did not ensure that resident received prescribed medication is deemed Substantiated. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citation and Appeal Rights (LIC 9058 01/16) was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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