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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:16:52 PM


Document Has Been Signed on 07/31/2023 01:16 PM - 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:
07/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Liliana Moreno, Medical TechnicianTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct a case management visit in reference to complaint number 18-AS-20211213132843. LPA met with Medical Technician Liliana Moreno and toured the facility. The facility was originally cited incorrectly on the form LIC9099-D on December 28, 2021. The citation should have been noted on a LIC809-D, and thus, this LIC809 was created to utilize.

During the visit on December 28, 2021, Staff One (S1) had been working inside the facility since August 13, 2021. On this date, the facility was cited an immediate $500.00 civil penalty in reference to the violation using the form LIC421-BG per Title 22.

An exit interview was conducted with Moreno and a copy of this form was discussed with along with copies of the LIC809-D, LIC421-BG and Appeal Rights were given.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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Document Has Been Signed on 07/31/2023 01:16 PM - 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: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
87355(d)(3)

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87355 Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted...

(3)The license shall submit these fingerprints to the California Department of Justice...prior to the individual's employment, residence, or initial presence in the facility. This requirement was not being met as evidenced by:
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Licensee removed S1 from the facility. POC has been cleared.
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Licensee did not ensure S1 obtained a criminal record clearance prior to beginning working at facility. Based on record review and interview, S1 had been working at the facility since 08/13/21. This poses an immediate health and safety 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: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2