336426759-8-30-2022-18-AS-CCON-CHSMVU-20220830095719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 08/30/2022
Date Signed: 08/30/2022 09:57:35 AM

Document Has Been Signed on 08/30/2022 09:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	TRACY LANGENDOEN		FACILITY TYPE:	740
ADDRESS:	25911 STANFORD ST		TELEPHONE:	(951) 925-7107
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	55	CENSUS: 52	DATE:	08/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diana Ramirez - Executive Director/Administrator		TIME COMPLETED:	10:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Diana Ramirez and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the facility's storage. LPA Colvin observed the facility to not have an adequate supply of PPE, specifically surgical masks and N95 masks. LPA Colvin was informed by care staff that they are currently relying on bringing their own to work. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note for the facility not having a 30-day supply of PPE instead of a deficiency, as LPA Colvin spoke with the Administrator and went over their plan to obtain additional masks. LPA Colvin went over the various recommended training for facility staff with Administrator Diana Ramirez in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Diana Ramirez informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a TA Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently have any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/30/2022

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LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Diana Ramirez confirmed that residents are being screened daily. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility, as LPA Colvin was today. LPA Colvin additionally confirmed that all facility staff are vaccinated, so the facility is not required to continue with surveillance testing weekly, and Administrator Diana Ramirez confirmed that both new staff and new residents must present a negative COVID-19 test prior to start of employment or residence at the facility.

An exit interview was conducted with Administrator Diana Ramirez and a copy of this report and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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