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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:31:38 PM


Document Has Been Signed on 10/26/2022 12:31 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:JUAN JORGE POEMAPE-DIAZFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:95CENSUS: 66DATE:
10/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Itzayana Barba, Operations ManagerTIME COMPLETED:
12:35 PM
NARRATIVE
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On today's date Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Incident inspection visit. LPA Quiroz was greeted and COVID-19 screened by front desk receptionist and met with Operations Manager Itzayana Barba. LPA Quiroz along with Operations Manager Itzayana Barba conducted a facility tour of the interior and exterior of facility premises. During today's visit, LPA Quiroz conducted interview with Operations Manager Barba and requested the following for review for (R1): Physician Report, Identification Form and Needs and Services Plan.

The purpose of this Case Management- Incident visit was to follow-up on a Special Incident Report received in the Orange County Regional Office on 10/18/2022 , dated 10/13/2022 regarding Resident 1 (R1) leaving the facility unassisted.

Per file review of Resident 1's physician report dated 9/13/2022 page 4 of 6; (R1) has a primary diagnosis of Dementia with behavioral disturbances, and indicated not able to leave the facility unassisted.

For this visit, deficiency was observed and citation was issued per Title 22 Division 6 of the California Code of Regulations. (SEE LIC 809-D) Civil penalty assessed on today's date.

LPA Quiroz conducted an exit interview with Operations Manager Barba. LPA Quiroz discussed the deficiency, citation, Civil Penalty and Appeal Rights. Copies of this report, Deficiency (809-D), Civil Penalty (421 IM) and Appeal Rights and copy of CCR 87705-Care of Persons with Dementia were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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Document Has Been Signed on 10/26/2022 12:31 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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited

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87705 Care of Persons with Dementia... In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering.. This requirement was not met as evidenced by:
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Based on observation, file review and interviews, facility failed to provide safety measures to address the wandering behavior of R1. R1 was able to leave the facility without assistance. This poses an immediate risk to residents in care.
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or related Cognitive impairment diagnose and submit POC to CCL by 10/28/2022.

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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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