<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:47:28 PM

Substantiated


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
09/30/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220930142325
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: 50DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Deanna Lewis - LVNTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not contact medical services for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with LVN Deanna Lewis and informed her of the purpose of today's inspection. Below is a summary of the findings:

Regarding allegation "Facility did not contact medical services for resident.": LPA Colvin reviewed the file for resident (R1), internal incident report for R1's most recent fall, and interviewed LVN Deanna Lewis regarding R1's fall. Record review and interviews reveal that on 9/29/22 during the overnight (NOC) shift, R1 was found by staff on the floor of their room. While R1 was first only observed to have a skin tear, records show that staff later observed R1 to have a bump on their head. NOC shift staff sent a text message to LVN Deanne Lewis, but did not contact 911 or R1's conservator (Public Guardian) to notify or seek medical attention. LPA Colvin inquired about the facility's policy for calling 911 when a resident falls, and LVN Lewis stated that 911 is to be called for any type of head injury. LPA Colvin asked if a bump on the head would meet this criteria, and LVN Lewis confirmed that it would and that NOC staff should have called 911 once they observed the bump.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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-20220930142325
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: 10/04/2022
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
26
27
28
29
30
31
32
At the hospital, it was later determined that R1 suffered from a brain bleed, which was separate from the brain bleed R1 had just been previously hospitalized for. Therefore, based on record review and interviews conducted, the allegation "Facility did not contact medical services for resident." 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.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to LVN Deanna Lewis during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220930142325
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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to retrain all care staff (and MedTechs) regarding policy on when to call 911 and for assessing residents after an unwitnessed fall. Licensee ot provide LPA Colvin with estimate on when all care staff will complete training by Plan of Correction date of 10/5/22. Licensee to additionally provide LPA
8
9
10
11
12
13
14
Based on record review and interview, the Licensee did not comply with the above regulation with one resident (R1). NOC shift staff observed R1 to have a bump on their head after an unwitnessed fall but did not contact emergency services. This was an immediate health & safety risk to R1.
8
9
10
11
12
13
14
Colvin with copy of signautres of all staff trained and their position at the facility.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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
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
09/30/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220930142325

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: 50DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Deanna Lewis - LVNTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide a safe environment for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with LVN Deanna Lewis and informed her of the purpose of today's inspection. Below is a summary of the findings:

Regarding allegation "Facility did not provide a safe environment for resident.": LPA Colvin conducted interviews and reviewed the files for R1. LPA Colvin observed that earlier in September 2022, R1 had an unwitnessed fall which resulted in R1 being hospitalized. R1 was returned to the facility on 9/28/22 at 6:30pm, at which time a fall mat was placed in R1's bedroom, and carestaff were instructed to condcut more frequent checks on R1. According to facility notes, that night (9/29/22) 40 minutes into the NOC shift, R1 was observed to have had an unwitnessed fall in their bedroom. While no new assessment had been conducted by the facility to address what other means the facility could put in place to ensure R1's risk for falling was addressed, R1 sustained an unwitnessed fall which resulted in another hospitalization. Despite the fall, the facility had put into place additional measures in the less than 24 hours since R1's return to the facility
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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-20220930142325
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: 10/04/2022
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
26
27
28
29
30
31
32
and their subsequent fall, such as the fall mat and additional staff checks. Due to the short period of time between R1's return to the facility and their next fall which resulted in another hospitalization, there is not enough evidence to suggest that the facility did not take additional reasonable safety measures to attempt to prevent additional falls. Interviews conducted revealed that the facility was attempting to get R1 placed on hospice prior to his discharge from the hospital on 9/28/22, so that R1 could have the additional support of a hospital bed with guard rails (which Title 22 Regulations require a resident to be on Hospice to have). Therefore, based on the measures taken by the facility, the short period of time that the resident was back at the facility, and lack of additional evidence, the allegation "Facility did not provide a safe environment for resident." is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with LVN Deanna Lewis and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5