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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880924
Report Date: 03/04/2025
Date Signed: 03/04/2025 04:05:44 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
02/25/2025 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250225135432
FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:VICKY TORRESFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 96DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator, Vicky TorresTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not give resident medication as prescribed
INVESTIGATION FINDINGS:
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On 3/4/25, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator, Vicky Torres who who was informed of the purpose of the visit.

It was alleged staff mismanaged Resident 1's (R1's) medication resulting in their hospitalization. LPA toured the facility, conducted interviews, and obtained copies of pertinent records. LPA reviewed R1's admission agreement dated 11/6/23 and section 14 notes medication will be monitored as prescribed by the Resident's doctor. LPA reviewed R1's Physician's Report for Residential Care Facilities for the Elderly dated 11/17/23 noting R1 does not have the capacity to store or administer their own prescription medications. LPA reviewed R1's assessment dated 1/9/25 noting R1 requires total assistance with medications. Administrator Torres was interviewed and reported when residents return from the hospital, the facility faxes the updated physician orders to the pharmacy who then enters the medication orders onto the facility's electronic Quick Medication Administration Record (QMAR).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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 4
Control Number 18-AS-20250225135432
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: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Administrator reported they will conduct an in-service staff training regarding proper medication management and documentation. Administrator added they will conduct their own quality assurance checks to avoid future medication errors.
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Based on interviews and records reviewed, a complaint investigation revealed facility staff mismanaged R1's medication resulting in their hospitalization. This poses a potential health, safety, or personal rights 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: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20250225135432
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: 03/04/2025
NARRATIVE
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The facility reported medication technicians follow the QMAR when dispensing residents’ medications. Medication technicians are able to review a list of routine medications titled “Physician’s Orders” (POs) which are automatically generated from the QMAR. LPA reviewed the POs dated June 19, 2024, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. LPA reviewed R1’s QMAR from October 2024 to March 2025. The QMAR dated October and November 2024 noted the medication in question was dispensed to R1 from October 1, 2024, to November 25, 2024, as directed in the POs dated June 19, 2024.

LPA reviewed R1’s QMAR dated December 2024, which indicated one and a half tablets of the medication in question was dispensed to R1 every Sunday. R1’s QMAR dated December 2024 did not document the medication in question was dispensed to R1 daily. Two (2) staff interviewed reported medication technicians are instructed to create a paper Medication Administration Record (MAR) to document dispensing a medication that is active but for an unknown reason is not listed in the QMAR. The facility provided LPA with an undated paper MAR noting the daily dosage of the medication in question was only dispensed to R1 on the 28th day of an unknown month.

LPA reviewed R1’s physician’s orders from the Kaiser Permanent After Visit Summary (KPAVS) dated 12/26/24, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. The facility reportedly faxed the KPAVS dated 12/26/24 to the pharmacy who entered R1’s medication orders in the QMAR. However, LPA reviewed the POs dated January 23, 2025, which noted only one and a half tablets of the medication in question to be dispensed every Sunday morning thirty minutes before breakfast. R1’s QMAR dated January 2025 corroborated the medication in question was only dispensed to R1 as directed in the January 23, 2025, POs. The facility searched but was unable to produce a paper MAR documenting the medication in question was dispensed to R1 daily in January 2025, as directed in the physician’s orders from R1's KPAVS dated 12/26/24. LPA reviewed the facility’s “Narrative Charting” noting R1 returned from the hospital on 2/23/25 and is to take the one tablet of the medication in question every morning and one and a half tablets every Sunday. LPA reviewed R1’s physician’s order from the KPAVS dated 2/23/25 noting the medication in question is to be administered one tablet every morning thirty minutes before breakfast and one and a half tablets every Sunday, with the next dose due on the morning of 2/24/25.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20250225135432
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: 03/04/2025
NARRATIVE
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LPA reviewed R1’s QMAR dated February 2025 which documented one and half tablets of the medication in question was dispensed to R1 on 2/2/25, 2/9/25, and 2/16/25 and one tablet daily beginning on 2/25/25. The QMAR dated February 2025 noted R1 was away from the facility from 2/18/25 to 2/24/25. One (1) of two (2) staff interviewed reported dispensing R1’s medication in question on 2/24/25 but was unable to produce a paper MAR to prove it. On 2/25/25, the Department received an incident report from the facility reporting on 2/17/25 R1 was sent to the emergency room due to being verbally unresponsive. LPA also reviewed R1’s Kaiser Permanente Progress Notes (KPPN) dated 3/3/25 noting R1 was recently hospitalized due to a medication error. The KPPN dated 3/3/25 noted R1’s medication in question was incorrectly entered into the care facility’s system and it was determined R1’s symptoms were due to lack of the medication in question. Health Services Associate, Carolina Campos reported supervisors are required to approve new medication orders entered onto the QMAR. The facility reportedly failed to verify the pharmacy entered the correct medication orders from the physician’s orders from R1’s KPAVS dated 12/26/2025, which reflected in the QMAR POs dated 1/23/2025 and resulted in the medication errors. One (1) of two (2) staff interviewed corroborated the allegation. R1 declined to be interviewed.

Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Torres.

*Note LPA was off-site from 1:05 p.m. to 1:35 p.m.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4