<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:10:02 PM

Unfounded


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
11/05/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211105101618
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:
11:11 AM
MET WITH:Charlie MarinkoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 training records. Regarding the allegation that staff are not properly trained, the investigation revealed the following: LPA reviewed training records for Staff 1 (S1). LPA observed required training hours including required medication training. Based on record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.
Unfounded
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 5
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
11/05/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211105101618

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:
11:11 AM
MET WITH:Charlie MarinkoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulting in resident developing open wound
Facility is understaffed
Staff are not maintaining residents hygiene
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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. Regarding the allegations that staff neglect resulting in resident developing open wound, facility is understaffed and staff are not maintaining residents hygiene, the investigation revealed the following: Resident 3 (R3) was diagnosed with Atherosclerotic Cardiovascular Disease per physician report dated 12/09/2019. There is no documentation of any wound in resident's file. Resident passed away in 2022. Facility staff states not being aware of any wound on the resident. Facility struggled with staffing due to the pandemic. Staff state the facility used agency at times or staff would work double shifts. Staff indicate meeting the resident's needs. Staff indicate residents were receiving showers or bed baths during isolation and the staff worked to the best of ability during the lockdown. Five out of five residents interviewed state needs being met by facility staff. Based on interviews conducted, LPA is unable to corroborate CONT ON LIC 9099C DATED 10/23/024
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: 2 of 5
Control Number 22-AS-20211105101618
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.


*This is an amended report to reflect "Unsubstantiated."
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)
Page: 3 of 5
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
11/05/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211105101618

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:
11:11 AM
MET WITH:Charlie MarinkoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to administer correct medicine to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 reviewed and obtained pertinent documentation such as medication adminisfration record (MAR). Regarding the allegation that Facility failed to administer correct medicine to residents, the investigation revealed the following: Resident 1 (R1) had a missed dosage of Donezepil HCI 10mg and Iron tablet 325mg on 10/29/2021. R2 had no missed medications per the MAR.
Based on the evidence gathered through record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted, and a copy of this report, and appeal rights were provided.
Substantiated
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: 4 of 5
Control Number 22-AS-20211105101618
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: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
Basic services shall at a minimum include: Personal assistance and care as needed by the resident, with those activities of daily living such.. assistance with taking prescribed medications,..This req is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide an in-service on medication administration and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on record review, Licensee failed to ensure resident was provided assistance with taking medication. This poses an immediate health and safety risk to 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5