306005603-11-1-2024-22-AS-SHAN-DALV28-20241101160243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 11/01/2024
Date Signed: 11/01/2024 04:03:07 PM

Document Has Been Signed on 11/01/2024 04:03 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 LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR/ DIRECTOR:	ITZAYANA BARBA AGUIRRE		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY: 95	TOTAL ENROLLED CHILDREN: 0	CENSUS: 85	DATE:	11/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:11 AM
MET WITH:	Charles Marinko		TIME VISIT/ INSPECTION COMPLETED:	01:55 PM

NARRATIVE

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On today’s date, Licensing Program Analysts (LPAs) Samer Haddadin and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs met with Executive Director administrator (ED) Charles Marinko. This facility is licensed to provide services to residents age range 60 and over. Approved for 95 non-ambulatory residents, of which 12 may be bedridden and has an approved hospice waiver for 20 residents. At time of visit, facility had total of 85 residents in which 5 are currently on hospice.

LPAs observed smoke detectors/carbon monoxide in common areas, hallways, and bedrooms; all were tested on August 22^, 2024, by Fire Safety Services Inc Fire. Fire extinguisher were fully charged with service tag indicating last inspection date was on November 13^, 2023. Fire drills are conducted quarterly with last drill conducted on September 30^, 2024.

Residents’ bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets were observed to be operational, grab bars were secure. Water temperature was tested in first spa room and measured at 106.8 degrees Fahrenheit. The second spa room, on second floor, measured at 106.5 degrees Fahrenheit; Resident’s one (R1) restroom water temperature measured at 107.7 degrees Fahrenheit; Resident’s (2) restroom water temperature measured at 107.7 degrees Fahrenheit.

On or about 9:41 AM, LPAs toured the kitchen area with ED and noticed multiple food items that were expired; one gallon of Reliance Heavy Duty Mayonnaise expired on September 24^,2024; one gallon of Reliance Mustard expired on September 11, 2024. One gallon of Coleslaw Dressing expired on August 28^,2024.

LPAs checked for 2-day supply of perishable, 7-day supply of non-perishable foods and emergency water; all were observed in today’s visit. Kitchen appliances were observed to be operational with sharps and knives being inaccessible to residents in care. (CONTINUE LIC 809C)...

Alisa Ortiz	TELEPHONE: (714) 703-2855
Samer Haddadin	TELEPHONE: (714) 790-2096
	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/01/2024

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LPAs toured the backyard of the facility and observed there was a shaded seating area and ample space for activities; all outside emergency exists were free of tripping hazards and or obstructions or barriers.

LAPs observed exit stairwells and each floor had an evacuation chair. Toxins were locked and inaccessible to residents. Medications were locked and inaccessible to residents.

First aid kit had all the required elements including bandages, tweezers, thermometer, scissors, and manual. LPAs reviewed 8 residents’ files and observed all files had all required documentation. LPAs also reviewed 4 staff files and observed all had the required documentation.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to AD at end of inspection.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/01/2024 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as multiple food items were observed to be expired in the kitchen which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 11/04/2024
	Plan of Correction
1 2 3 4	Staff immediately removed expired items from kitchen area and will provide LPA proof of staff training documentation via email by POC date. Licensee will ask manifature to provide expiration dates on items

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024

LIC809 (FAS) - (06/04)

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