306005603-2-6-2024-22-AS-AORZ-D2FQQ6-20240214112147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 02/06/2024
Date Signed: 02/06/2024 11:42:04 AM

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
01/29/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240129094914

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: 82	DATE:	02/06/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Lynn Vuong and Yaya Garcia		TIME COMPLETED:	12:03 PM

ALLEGATION(S):

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Facility staff who are not skilled professionals are performing glucose testing on resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. 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, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as medication administration record. Regarding the allegation that facility staff who are not skilled professionals are performing glucose testing on resident, the investigation revealed the following: Resident 1 (R1) requires glucose testing. Physician report dated 08/31/2022 indicated resident is able to manage medications as well as perform own glucose testing. However, two out of three med techs as well as resident confirm staff is assisting with glucose testing. Staff are not appropriately skilled professionals. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation 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 and a copy of this report along with the Appeal Rights were provided at the time of this visit.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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 4

Control Number 22-AS-20240129094914

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: 02/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/07/2024 Section Cited CCR 87628(a)	1 2 3 4 5 6 7	The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens..., or has it administered by an appropriately skilled professional. This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct an in-service to staff and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, Licensee failed to ensure glucose testing is performed by an appropriately skilled professional. Staff are performing glucose checks on R1. 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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/29/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240129094914

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: 82	DATE:	02/06/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Lynn Vuong and Yaya Garcia		TIME COMPLETED:	12:03 PM

ALLEGATION(S):

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Staff did not distribute resident's medication as prescribed
Staff do not ensure that resident takes medications
Staff do not ensure that medications are stored inaccessible to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an 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, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as medication administration records. Regarding the allegations that staff did not distribute resident's medication as prescribed, staff do not ensure that resident takes medications, and staff do not ensure that medications are stored inaccessible to residents in care, the investigation revealed the following: On 01/29/2024, Staff 1 (S1) asked resident if the resident wanted the morning medications at the med cart. R1 took issue with the staff asking about the medication instead of just giving the medication without conversation. An altercation ensued and resident left the medication cart without taking morning medications. Evening medications were administered normally. Three out of three staff indicated resident is generally compliant with medication administration. CONT ON LIC 9099 DATED 2/6/24

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20240129094914

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: 02/06/2024

NARRATIVE

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Resident indicated morning medications are administered with food and the staff administer the medication with the resident's breakfast. However, R1 stated that the resident prefers to take medications unobserved and without staff present. R1 denies refusing medications on this instance or any occasion. Three out of three staff deny allowing resident to walk out of sight with medications and residents are required to take the medication in front of the staff. Due to conflicting information, 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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4