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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 05/23/2023
Date Signed: 05/23/2023 11:37:25 AM


Document Has Been Signed on 05/23/2023 11:37 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 55DATE:
05/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Diana Ramirez, Executive DirectorTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver an amended report (18-AS-20211018132918). As part of the visit, LPA toured the facility. During the tour, LPA found the following deficiencies:
  • Call buttons do not work in a resident room
  • No alternatives to the menu

Facility was issued two citations per Title 22. An exit interview was conducted where a copy of this report was provided along with copies of the LIC809D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (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.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/23/2023 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 B
05/30/2023
Section Cited
CCR
87555(b)(5)

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General Food Service Requirements: (b) The following food service requirements shall apply:(5) Meals shall consist of an appropriate variety of foods..This requirement was not being met as evidenced by:
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Licensee held a staff meeting with their Culinary Director and supplied proof of converstation about ordering the items listed on the menu. POC cleared at time of visit.
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Staff interview indicated that multiple meal alternatives were not available to be provided to residents in care. This poses a potential personal rights risk to residents in care.
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Type B
05/30/2023
Section Cited
CCR8746.2(a)(8)

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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(8) To be free from neglect...this requirement was not being met as evidenced by:
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Licensee fixed the call button and LPA saw that it functions properly. POC cleared at time of visit.
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Based on LPA observation, Resident did not have a call button that was working to alert staff of their needs. This poses a potential personal rights risk to residents in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 2 of 2