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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:12:22 PM

Document Has Been Signed on 10/23/2024 03:12 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 LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR/
DIRECTOR:		ITZAYANA BARBA AGUIRREFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 95CENSUS: 76DATE:
10/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Charlie MarinkoTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in-conjunction with complaint visit 22-AS-20210623133139. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA reviewed Resident 1's (R1) file. Resident did not have an updated physician report. Physician report dated 12/06/2018 indicates a diagnosis of Dementia.



Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiency.

Exit interview conducted and a copy of this report was provided along with appeal rights

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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Document Has Been Signed on 10/23/2024 03:12 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/23/2024 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
CCR
87705(c)(5)

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Each resident with dementia shall have an annual medical assessmentt, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This req is not being met:
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Licensee to provide an in-service on ensuring residents with Dementia have updated physician reports and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure R1 received an updated physician report due to diagnosis of Dementia. This poses a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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