306005603-9-12-2022-22-AS-RQUZ-CJ7SZY-20220912141955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:21:12 PM

Document Has Been Signed on 09/12/2022 02:21 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CITRUS HILLS ASSISTED LIVING		FACILITY NUMBER:	306005603
ADMINISTRATOR:	JUAN JORGE POEMAPE-DIAZ		FACILITY TYPE:	740
ADDRESS:	142 S PROSPECT ST		TELEPHONE:	(714) 639-3590
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	95	CENSUS: 51	DATE:	09/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Itzayana Barba, Health Wellness Director and Ryan Mims, Maintenance Director		TIME COMPLETED:	12:10 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Front desk Receptionist. LPA Quiroz met with Itzayana Barba, Health and Wellness Director (HWD) and explained the nature of the visit.

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. The facility is providing services to (4) four Hospice residents at this time.

(HWD) Barba indicated Juan Jorge Poemape Diaz, Operations Manager (OM) is currently not present at the facility and indicating "Company is currently hiring for (ED) position as (OM) Poemape-Diaz is resuming a new position with the company. However Juan Jorge Poemape-Diaz and Phat Nguyen are covering the Administrator duties." Administrator Juan Jorge Poemape-Diaz has an Administrator certificate with expiration date of 11/04/2023.

On or about 9:58am LPA Quiroz along with (HWD) Barba toured the inside and outside of facility. All staff working at facility were observed to be wearing face masks upon arrival to facility. There are fifty-one (51) residents in care and there are no active COVID-19 cases.

On or about 10:18am, LPA Quiroz along with Food Service Manager toured the kitchen area. During today's inspection visit, LPA Quiroz observed residents in their rooms resting, in activity room, in front area of facility smoking in designated facility smoking area and eating their lunch.

On or about 10: 40am, while LPA Quiroz along with (HWD) Barba toured laundry area, LPA Quiroz observed bucket of opened laundry detergent without lid. (HWD) Barba removed laundry detergent from laundry area immediately.

CONTINUED ON NEXT PAGE....

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CITRUS HILLS ASSISTED LIVING	FACILITY NUMBER: 306005603
	VISIT DATE: 09/12/2022

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At 11:30am, LPA Quiroz provided consultation on CCR 87705(f)(2) with (HWD) Barba and Maintenance Director (MD) Ryan Mims. On or about 12:45pm, while LPA Quiroz along (MD) Mims conducted a facility inspection tour addressing Complaint control #:22-AS-20211119134410, LPA Quiroz observed a bag of Tide pods Laundry detergent on laundry basket on top of chair next to laundry area without staff supervision. This was verified with (MD) Ryan Mims. This poses a potential risk to residents in care. (See LIC 809-D).

The residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer. LPA Quiroz inspected residents’ bedrooms with all required components. LPA Quiroz observed a check in station and resident/visitor log-in in the main entry of the facility.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies stored in storage room on second floor.

LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment in court yard on first floor and second floor balcony. Facility has completed the LIC 808 Mitigation plan, which was approved by LPA Micah Martinez on 3/12/2021 and has submitted an Infection Control Plan.

Based on the observation made during today’s visit, deficiency was noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (HWD) Itzayana Barba, and a copy of this report, LIC 809-D, and Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2022 02:21 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
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: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(2)

This requirement is not met as evidenced by: On today's date, at 10:40am while conducting facility inspection tour along with HWD Barba, LPA Quiroz observed open container of laundry detergent without lid. This was verified with HWD Barba and corrected immediately. At 11:30am, LPA Quiroz provided consultation on CCR 87705 (f)(2) with Maintenance Director Ryan Sims. At 12:45pm, LPA Quiroz conducted inspection tour with Maintenance Director and observed a Tide pods laundry detergent inside laundry baskey on top of chair right next to laundry area with no staff supervision around. This was verified with MD Sims. This poses a potential risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview), the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	HWD Itzayana Barba will conduct an inservice with staff and residents on CCR 87705 and submit proof to CCL by 9/16/2022.

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: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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