306005603-5-15-2024-22-AS-AORZ-D5PRX4-20240528132404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:11:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/23/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240223130422

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: 80	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Cindy Mora-Receptionist, Lynn Vuong-Business Office Manager		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 23, 2024. LPA was greeted and granted entry into the facility and met with receptionist Cindy Mora. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that staff did not seek timely medical attention for a resident. Resident 1 (R1) was admitted to the facility on July 28, 2023. Documents reviewed included the Physician Report (LIC602) dated July 27, 2023 for R1. Per Physician report R1 is able to communicate their needs. During the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated January 17, 2024 for R1. Per UIIR on January 12, 2024 R1 had an unwitnessed fall and R1 was helped up. Per UIIR wound care was completed on R1's skin tear. During the course of the interviews with residents, R1 reported that she has not had a fall that made her head bleed. Per R1 is she needed to go to the Hospital staff would call 911.
CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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-20240223130422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CITRUS HILLS ASSISTED LIVING	FACILITY NUMBER: 306005603
	VISIT DATE: 05/15/2024

NARRATIVE

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R2 stated that he has not needed medical attention and reported that if he did that staff would call 911. During the course of the interviews with staff, Staff 1 (S1) stated that if a resident's head is bleeding that staff would call 911.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

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