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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005603
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:43:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2021 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211119134410
FACILITY NAME:CITRUS HILLS ASSISTED LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR:TANJA OLANOFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:95CENSUS: 51DATE:
09/12/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Itzayana Barba, Health and Wellness Director and Ryan Sims, Maintenance Director. TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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-Facility is unclean
INVESTIGATION FINDINGS:
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced subsequent visit following a Required Annual inspection visit to the facility. The purpose of today's visit was to address the allegation listed above. LPA Quiroz met wtih Health and Wellness Director (HWD) Itzayana Barba and Ryan Mims, Maintenance Director (MD) and discussed purpose of today's visit.
On today's at 12:45pm, LPA Quiroz along with (MD) Mims toured the facility, inspecting the physical plant and conducted interviews with interviewees. LPA Quiroz observed spider webs, dust, trash throughout hallways, hallways lamps, underneath residents beds and resident apartment floors. On today's date at 10:36am while conducting Annual inspection tour visit along with (HWD) Itzayana Barba, LPA Quiroz observed stains in Resident 1's (R1) bathroom area and detected urine odor on carpet in R1's apartment, this was verified with (HWD) Barba.
Based on observations conducted by LPA Quiroz on 11/23/2021, today's date and interviews conducted with interviewees; the allegation "facility is unclean" is deemed substantiated.
CONTINUED ON NEXT PAGE...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20211119134410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited
CCR
87303(a)(1)
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87303(a)(1)Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...(1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. CONTINUED BELOW
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HWD Barba and MD Mims indicated they will hire new Housekeeping staff, update schedule and add R1 to waiting list for carpet/bathroom floor replacement. HWD will conduct inservice training with staff on communication to Housekeeping staff regarding CCR 87303 and submit proof by POC due date of 9/16/2022.
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This requirement was not met as evidenced by: On 11/23/2021 and today's date at 12:45pm, LPA Quiroz along with (MD) Mims toured the facility, LPA Quiroz observed spider webs, dust, trash throughout hallways, hallways lamps,underneath resident's beds and floor area CONTINUED...
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On today's date at 10:36am while conducting Annual inspection tour visit along with (HWD) Itzayana Barba, LPA Quiroz observed stains in R1's bathroom area and detected urine odor on carpet, this was verified with (HWD) Barba. This poses a potential risk for 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20211119134410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
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The following deficiency noted on the LIC 9099-D is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with (HWD) Itzayana Barba, and a copy of this report, LIC 9099-D, LIC 811-Confidential Names, Appeal rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 3