306006033-11-15-2022-22-AS-JHAY-CL829A-20221115161138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006033
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:11:45 PM

Document Has Been Signed on 11/15/2022 04:11 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:	CITRINE RESIDENTIAL CARE		FACILITY NUMBER:	306006033
ADMINISTRATOR:	CELIS, PRISCILLA		FACILITY TYPE:	740
ADDRESS:	3359 W ORANGE AVE		TELEPHONE:	(949) 573-6489
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 5	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Priscilla Celis		TIME COMPLETED:	04:20 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Priscilla Celis arrived after the inspection started and was present for the remainder of the visit. AD Celis has a current administrators certificate that expires 07/7/23.

At 2:35 PM LPA Haley and staff began the inspection at the entrance of the facility. There were five clients present during the visit. A screening station with hand sanitizer and screening log books was observed near the front door. A temperature thermometer was mounted on the wall.

LPA Haley observed a staff room right next to the front door. Across from the staff room is resident bedroom 1 with a bathroom. All resident bedrooms had the necessary items: bed, chair, lamp, and storage space. Resident bathrooms were clean and organized. Hot water temperature was measured at 111.0 degrees Fahrenheit in bathroom #1, 107.2 degrees Fahrenheit in bathroom #2, and 105 degrees Fahrenheit in bathroom #3

In the hallway closet next to bedroom #3 LPA Haley observed plenty of adult diapers. In the hallway closet across from bedroom #3, plenty of clean linen was observed on the left side of the closet, and more adult diapers was observed on the right side of the closet.

LPA Haley observed a locked medication cabinet in the living room used to store client medication. A supply of emergency items was observed in the living room across from the locked medication cabinet. LPA observed 5 five gallon jugs of water, two buckets of emergency food, flash lights, a generator, and several other emergency items. Furthermore, an emergency supply of PPE was observed with the other emergency supplies. Across the living room a printer and several training manuals were observed under the printer. In the file cabinet under the computer, LPA observed resident and staff files.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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: CITRINE RESIDENTIAL CARE	FACILITY NUMBER: 306006033
	VISIT DATE: 11/15/2022

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In the kitchen LPA Haley observed a drawer to the left of the sink where all the knives and sharp objects were located. A seven day supply of non-perishable food items was observed in the cabinets, and a two day supply of perishable items was observed. In the dining room LPA observed a fully charged fire extinguisher mounted on the wall.

There's an additional room next to the dining room and it's used as an activity room for the residents. The activity room was clean and organized. LPA observed a TV, several board games, cards, small foot/leg exercises machine, and other activities.

The backyard had clear walkways, free of tripping hazards. There was a side exit gate that was self closing and self latching. LPA Haley observed a table, chairs and a sun shade.

The garage had clear walkways free of tripping hazards. A washer and dryer was observed. above the washer and dryer were locked cabinets with hazardous cleaning items. Across from the washer and dryer was another locked cabinet with laundry detergents, bleach and other hazardous cleaning items. Further, LPA observed a staff refrigerator, and a freezer with additional food items for the residents. Plenty of additional items for the facility are kept in the garage. LPA observed a Hoyer lift, several wheelchairs, a walker, mattresses, bed frames, tables and chairs.

No bodies of water were observed during today's visit. All smoke detectors and carbon monoxide detectors tested operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report and LIC 9102 was provided to Administrator Celis.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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