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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006033
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:10:36 PM


Document Has Been Signed on 07/26/2023 02:10 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CITRINE RESIDENTIAL CAREFACILITY NUMBER:
306006033
ADMINISTRATOR:CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:3359 W ORANGE AVETELEPHONE:
(949) 573-6489
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 4DATE:
07/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Priscilla CelisTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility to conduct a case management to follow up on information regarding a resident’s death. LPA arrived at facility was greeted and granted entry into the facility by staff. Pricilla Celis, Administrator arrived shortly after and met with LPA. LPA explained the nature of the visit.

During LPA’s visit, LPA toured the physical plant of the facility, reviewed resident's file and obtained copies of pertinent documentation and conduced interview with staff regarding the death of resident 1 (R1) who passed away on July 18, 2023. LPA interviewed AD Celis, and staff (S1) for further information regarding the death of R1 and the events that led up to R1’ death. Per AD Celis, the official Death Certificate had not been issued at this time and Anaheim PD gave AD information for Orange County Coroner’s office report as well as police report for further information if needed.

There was no preliminary cause of death that was determined or provided. LPA advised AD Celis to forward any copies of reports or information regarding R1’s death to LPA as soon as it is available or obtained.

No deficiencies were cited during this visit.

An exit interview was conducted, with Administrator and a copy of this report was provided and left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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