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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 02/01/2023
Date Signed: 02/02/2023 07:06:08 AM


Document Has Been Signed on 02/02/2023 07:06 AM - 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: 81DATE:
02/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Itzayana Barba AguirreTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit for the purpose of following up on a self reported incident report (SOC341) received in the Orange County Regional Office (OCRO) on 01/31/2023 regarding a physical altercation involving 2 residents. LPA met with Jermani Edmonds, Director Community Liaison and discussed the purpose of the visit. Operations Manager (OM) Itzayana Barba Aguirre arrived shortly after.

The report states that on 01/30/2023 around 12:30 PM, Resident 1 (R1) bumped into and Resident 2 (R2) table in the dining room. R1 apologized but R2 stated R1 did it on purpose. They got into a verbal altercation. R1 punched R2 with a closed fist to the left side of the face. R2 threw a glass cup at R1 that cut R1's right eye and eyebrow. 911 was called and R1 was taken to Chapman Global Hospital.

During today's visit, LPA received copies of incident report dated 1/31/2023 involving R1 and R2; incident report dated 1/13/2023 involving R2 and R3; and incident report dated 9/4/2022 involving R1 and R4 Also received copy of 30-Day Eviction Notice served to R1 and R2; a copy of Resident roster and LIC500 Staff schedule. Per OM, Police and family were notified. R1 and R2 have previous incidents with other residents. Both have been served with a 30-Day notice of eviction. OM stated copies of the 30-Day were sent to the Regional Office on 1/30/2023.

LPA Martinez interviewed both R1 and R2 and both are doing well. R1 did share concern for receiving the eviction notice and is hopeful it can be rescinded. Both R1 and R2 stated there was staff present in the dining area when altercation happened.

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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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