336426759-5-23-2023-18-AS-JESL-CTA62L-20230629202544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 05/23/2023
Date Signed: 05/23/2023 10:06:03 AM

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
10/18/2021 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211018132918

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: 53	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Monica Quinones, Wellness Coordinator		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Resident wandered away from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived a the facility and met with Receptionist Alyssa Rodriguez and Activities Director Reina Celaya. LPA Gardner made Ms. Rodriguez aware of the above allegation. The above allegation was in reference to a complaint generated due to a resident (R1) getting out of the facility on dates 10/12/21, and 10/15/21.

During the tour of the facility, LPA observed the door adjacent to R1's bedroom was able to be unlocked and did not have an auditory device to alert staff that the door was open or could be opened. At the conclusion of interviews, it was determined that R1 was able to exit the facility without detection by staff. During the inspection, LPA Gardner observed the door to be absent of an auditory device or other staff alert feature that would alert staff if door was left open or opened.

Based on interviews and and observstions made on 10/21/2021, this allegation was deemed to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. A copy of this report was reviewed with and provided along with copies of the LIC9099-D, and Appeal Rights. This is an amended version of the original report dated 10/21/2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211018132918

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 GARDENS	FACILITY NUMBER: 336426759
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/24/2023 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Upon visit, LPA observed auditory device installed as well as a combination lock installed on the door. POC cleared on visit.
	8 9 10 11 12 13 14	Based on observation, LPA found that there was not a working auditory device which would alarm staff if a resident were to leave the facility. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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