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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 04/12/2021
Date Signed: 04/28/2021 02:26:26 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/11/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210311100450
FACILITY NAME:CITRUS GARDENSFACILITY NUMBER:
336426759
ADMINISTRATOR:TRACY LANGENDOENFACILITY TYPE:
740
ADDRESS:25911 STANFORD STTELEPHONE:
(951) 925-7107
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:55CENSUS: 29DATE:
04/12/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Shannon HundleyTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not issue a refund to authorized representative after resident's death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to deliver findings for the above allegation. LPA contacted the facility via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Administrator, Shannon Hundley. The investigation consisted of interviews with staff/residents and records review.

LPA interviewed Staff #1 (S1) who stated that as of the morning of 3/16/2021, Resident #1's (R1's) Responsible Party did not receive a refund from the facility due to a delay with the facility's accounting department. LPA reviewed a copy of the check that was provided to R1's Responsible Party which was dated 3/16/2021. LPA interviewed S1 and R1's Responsible Party who both stated that R1's belongings were picked up and/or donated to the facility the week following R1's death. According to Title 22 Regulation's and R1's Admission Agreement, a refund should have been issued 15 days after R1's death, which occurred on 1/9/21, and after all of R1's belongings were removed from the facility; therefore, the allegation is SUBSTANTIATED.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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 3
Control Number 18-AS-20210311100450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
VISIT DATE: 04/12/2021
NARRATIVE
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Based on evidence gathered during the investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Hundley via telephone and a copy of this report (LIC 9099 & LIC 9099D) was provided via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210311100450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2021
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property;... (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been rremoved from the facility... within 15 days after the personal property is removed. This requirement has not been met as evidenced by:
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Plan of correction has been met as of 3/16/2021. A copy of the refund check was sent to LPA via email. LPA also confirmed with R1's responsible party that a refund was issued to them.
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Based on interviews and records review conducted, LPA confirmed that R1's responsible party did not receive a refund within 15 days after R1's personal property was removed following R1's death.
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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3