306005603-10-27-2023-22-AS-AORZ-CX4K3Z-20231030073331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 09/26/2023
Date Signed: 10/27/2023 02:07:45 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
08/02/2023 and conducted by Evaluator Andrea Mendivil

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230802103141

FACILITY NAME:	CITRUS HILLS ASSISTED LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR:	ITZAYANA BARBA AGUIRRE		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	95	CENSUS: 84	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Itzy Barba Aguirre		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident eloped due to staff negligence

INVESTIGATION FINDINGS:

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On this Day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Wellness Director Yairell Garica and explained the reason for the visit.

The department received a complaint on 08/02/2023 and LPA Mendivil conducted the initial 10 day visit on 08/11/2023. During the course of the visit LPA Mendivil interviewed residents and staff and obtained copies of pertinent records. Regarding the allegation resident eloped due to staff negligence, the investigation revealed the following:

Based on interviews with Staff 1 (S1) Resident 1 (R1) had made it out of the facility shortly after R1 had been admitted to the facility. After this incident R1 was given a wander guard which would sound an alarm if the R1 was to leave the building. Per review of a LIC 624 Unusual Incident/Injury Report dated 08/07/2023
Cont on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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-20230802103141

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: 09/26/2023

NARRATIVE

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indicated that R1 eloped from the facility and was found by neighbors at an elementary school down the street. R1 was returned to the facility and her wander guard was replaced to ensure it is fully charged. Based on interviews with 2 out of 2 residents indicate they have not witnessed any residents wandering out of the facility and staff responds to wander guard alarms quickly. Per interview with S1 wander guards are changed every 3 months and there is a staff member that conducts weekly testing.

During LPA Mendivil's follow up visit on 08/22/2023 LPA Mendivil had staff test the wander guard system. LPA Mendivil observed a loud alarm sound when the wander guard was beyond the facility doors. LPA Mendivil observed multiple staff respond to the alarm within 15 seconds. Per interviews with 2 out of 2 staff indicate the resident had wandering behaviors and the wander guard was provided to assist, but the facility is not a memory care or locked facility.

Therefore, based on evidence through records reviewed, interviews and observations the allegation resident eloped due to staff negligence, is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8 on a case management.

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

* this report was amended due to technical difficulties.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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