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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:26:39 PM


Document Has Been Signed on 06/06/2024 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR:ITZAYANA BARBA AGUIRREFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:95CENSUS: 81DATE:
06/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Itzayana Barba Aguirre-AdministratorTIME COMPLETED:
04:41 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on a self-reported incident regarding stolen medication. The incident report was received by Community Care Licensing (CCL) on April 29, 2024. LPA was greeted and allowed entrance into the facility by Administrator (AD) Itzayana Barba Aguirre. LPA explained the reason for the visit.

LPA conducted a toured of the inside and outside of the facility as well as bedroom of Resident 1 (R1).

Incident report dated April 26, 2024 states that on April 22, 2024 R1 missed a dose of their medication due to another resident taking their bubble pack.

During today's visit LPA reviewed documents including the Citrus Hills Assisted Living In-Service trainings dated April 22, 2024 and April 25, 2024 on how to lock and unlock the medication cart/how to ensure medication carts are locked/what to do if a narcotic count is off. Per AD the facility has also implemented a Plan of Action to prevent medications from being stolen in the future. AD reported that the Plan of Action will include that the Medication Technician (MT) keeps the keys with them at all times, the MT will double check that the medication cart is locked before stepping away and the MT will do a medication count at the end of every shift.

During' today's visit LPA observed the MT passing out medication. LPA observed as the MT locked the medication cart before stepping away.

An exit interview was conducted with AD Barba and a copy of this report was provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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