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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:08:37 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
06/23/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210623133139
FACILITY NAME:CITRUS HILLS ASSISTED LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR:TANJA OLANOFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:95CENSUS: 76DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Charlie MarinkoTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Facility staff did not notify resident's physician about changes in resident's condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as hospice records. Regarding the allegations that facility staff did not notify resident's physician about changes in resident's condition and resident sustained pressure injuries while in care, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 04/06/2019 with an initial hospice admission on 12/25/2020 for protein calorie malnutrition. Resident re-certified for hospice 03/17/2021. Hospice records and physician report dated 03/30/2021 indicated resident had multiple skin tears. Hospice documentation shows resident was being seen multiple times a week from 12/25/2020-05/29/2021. Wound care was being provided. Hospice documentation dated 02/08/2021 indicated half rails and fall pads were ordered for the resident. Hospice documentation is signed by hospice physicians indicating the CONTINUED ON LIC 9099C DATED 10/23/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 2
Control Number 22-AS-20210623133139
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: 10/23/2024
NARRATIVE
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physician was aware of the resident's condition at the time. Based on record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
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