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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:21:03 PM

Unsubstantiated


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
01/17/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230117080632
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: 54DATE:
06/19/2023
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Diana Ramirez, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not notify authorized representative of resident's room change
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Diana Ramirez, and informed her of the purpose of her visit.

The investigation included staff/resident interviews, records review, and records collection. The Department received a report alleging staff moved Resident One (R1) to another bedroom on or before December 25, 2023, and did not notify their authorized representative. A Face Sheet revealed two contacts, for R1, available for notification, one of which was identified as the Responsible Party and the other as the Alternate Contact. Staff interviews and resident daily notes revealed R1 contracted a contagious illness on December 23, 2022. Interviews revealed R1's illness required isolation from other residents. A staff interview revealed R1's authorized representative was contacted on December 24, 2023, of R1 being isolated in another bedroom. However, R1's authorized representative revealed being notified only after they contacted the facility for a separate matter. There was no documentation found on file of the staff's notification to the authorized
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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-20230117080632
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
VISIT DATE: 06/19/2023
NARRATIVE
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representative. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

This report was reviewed with Ramirez and a copy was provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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
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
01/17/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230117080632

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: 54DATE:
06/19/2023
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Diana Ramirez, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Diana Ramirez, and informed her of the purpose of her visit.
The investigation included staff/resident interviews, records review, and records collection. A report was received alleging staff were not assisting R1 to maintain the cleanliness of their fingernails. R1 was interviewed, though could not provide a statement regarding the matter. Staff interviews revealed resident's fingernails are maintained by Staff One (S1). S1 was interviewed and reported R1's fingernails are being maintained regularly, though, not when the resident was in isolation. S1 reported R1's fingernails were dirty on or around January 16, 2023; however, it was the first time the staff was able to address the nails after the resident's isolation. S1 reported to have assisted in maintaining R1's nails before and after R1's isolation. Therefore, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. This report was reviewed with Ramirez and a copy was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/17/2023 and conducted by Evaluator Stephanie Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20230117080632

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: 54DATE:
06/19/2023
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Diana Rodriguez, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not notify authorized representative of resident's injuries
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Diana Ramirez, and informed her of the purpose of her visit.
The investigation included staff/resident interviews, records review, and records collection. A report was received by the Department alleging Resident One (R1) sustained multiple injuries (i.e., a blister to their left foot and a 'knot' on their head and wrist) which were not reported to R1's authorized representative. Narrative Charting revealed R1 was observed to have sustained a blister on December 23, 2022, and the notes do not document any notification to R1's authorized representative. R1's representative was interviewed and reported having no knowledge of R1's blister. Investigation could provide no further information to corroborate or refute the validity of the additional alleged injuries. Therefore, based on records and interview, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. This report was reviewed with Rodriguez and a copy was provided, along with instructions on appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
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-20230117080632
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: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87468.1(a)(8)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following rights: (8) To have their representatives regularly informed...of activities related to care or services...as appropriate to their needs. This requirement wasn't met, as evidenced by: Based on records & interview,
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The Administrator will conduct a policy change to ensure the responsible parties of residents who receive additional services from hospice agencies will also be notified by the facility. The Administrator stated a copy of the change will be provided.
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the Licensee didn't ensure R1's representative was informed of R1's injury. A Narrative Report revealed R1 was observed w/ a blister & notes don't document notification to R1's representative. R1's representative reported having no knowledge of the blister. This posed a potential threat to R1's personal rights.
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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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5