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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880924
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:30:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 18-AS-20220204163100
FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 111DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Vicky TorresTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff failed to refill resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration record (MAR). Regarding the allegation that staff failed to refill resident's medication, the investigation revealed the following: Per MAR, Resident 1 (R1) did not receive Tamulosin HCL on 01/16-01/19/2022 and on 01/31/2022 pending delivery of the medication. Facility staff indicated R1's medications are serviced through the VA pharmacy and facilitated by the resident's family member. Witness indicates facility failed to provide adequate notice when refills were due. Facility documentation on 01/12/2022 shows that the family member had visited the facility and medications were to be delivered. There is no documentation of requests by the facility to request refills during the time of the complaint. Based on records reviewed and interviews conducted, the allegation is deemed substantiated. Citation is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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 5
Control Number 18-AS-20220204163100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS PLACE
FACILITY NUMBER: 331880924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87464(f)(4)
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Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing.. and assistance with taking prescribed medications. This req is not being met as evidenced by:
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Licensee to provide an in-service to staff on medication administration and forward proof to LPA by POC due date.
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Based on record review and interviews conducted, Licensee failed to ensure resident was assisted with medication administration. Resident missed five doses of medications as they were not refilled. This poses an immediate health and safety risk to 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 18-AS-20220204163100

FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 111DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Vicky TorresTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff handling medication are not qualified
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPAs toured the facility and interviewed staff and witness, Regarding the allegation that staff handling medication are not qualified, the investigation revealed the following: Per department regulations, Medication Technicians are not required to hold a nursing license. LPA reviewed training documents for select Medication Technicians and all had required annual training. Therefore the allegation is deemed to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit Interview conducted and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 18-AS-20220204163100

FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 111DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Vicky TorresTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility is serving cold meals
Facility in disrepair
Staff neglect lead to resident's fall
Administrator is unresponsive to resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as incident reports and work orders. Regarding the allegations that facility is serving cold meals, facility in disrepair, staff neglect lead to resident's fall and administrator is unresponsive to resident's responsible party, the investigation revealed the following: Resident 1 (R1) preferred meals taken in the room. Two out of two staff interviewed confirm assisting resident with eating as necessary and state the resident would go to the dining room with coaxing. Staff indicated with time the resident became more comfortable with the dining room and would go more frequently. Five out of five residents interviewed confirm food is warm when delivered and state no issues with food service. Facility provided work orders outlining the time frame for repair to R1's bathroom heater.
CONTINUED ON LIC 9099C DATED 12/03/2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220204163100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CITRUS PLACE
FACILITY NUMBER: 331880924
VISIT DATE: 12/03/2024
NARRATIVE
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Work order and interview with Maintenance Director indicated an order for repair was generated on 01/25/2022. Maintenance Director indicated unsuccessfully attempting to repair the item and then ordering the part on 01/28/2022. Due to the pandemic, specialty items took longer to receive and on 02/09/2022 the framing in the ceiling was repaired with the project completed on 02/10/2022. LPA observed the repaired area in the resident's room. Needs and Services Plan dated 01/11/2022 indicated resident was independent with ambulation and transfers but used a walker. LPA reviewed incident report dated 01/18/2022 showing the resident had come down to the lobby with a bleeding arm at 3:50 AM. Resident was immediately assessed. Per the report and narrative charting, resident's family member was notified of the incident at 4:32 AM with the family member arriving approximately 40 minutes later to the facility. Interview with Administrator at time of the complaint confirmed speaking with the resident's family member frequently regarding the resident's status. Narrative charting documented frequent interactions between resident's family member and staff regarding the status of the resident. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED, meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred.
An exit interview was conducted and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5