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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880924
Report Date: 11/19/2024
Date Signed: 11/19/2024 04:17:05 PM

Document Has Been Signed on 11/19/2024 04:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR/
DIRECTOR:		VICKY TORRESFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 140CENSUS: 117DATE:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:46 AM
MET WITH:Vicky TorresTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint visit 18-AS-20211215084528. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

During the complaint investigation, LPAs reviewed facility documentation and interviewed staff. Interviews conducted and records reviewed indicated R1 remained in the bedroom of the apartment while the living room ceiling was being repaired. Photos show the extent of the damage that occurred in the living room. Interviews conducted show that facility offered to move the resident into another room but responsible party refused due to the room not offering the same safety precautions as the resident's current room. Per physician report dated 09/28/2020, R1 is diagnosed with Mild Cognitive Impairment.






Based on the observations made during today's visit, the following citation is being cited per 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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Document Has Been Signed on 11/19/2024 04:17 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 11/19/2024 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CITRUS PLACE
FACILITY NUMBER: 331880924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2024
Section Cited
CCR
87468.1(a)(2)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This req is not being met as evidenced by:
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Licensee to submit a statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on observation, interviews conducted and record review, Licensee failed to ensure R1 was provided safe and healthful accommodations. R1 remained in the resident's room while a substantial repair was being done.
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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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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