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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 04/18/2025
Date Signed: 04/18/2025 10:56:24 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
12/23/2022 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 18-AS-20221223121913
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: 53DATE:
04/18/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Liliana Moreno, Med-Tech Supervisor/ AdministratorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Resident developed a Stage 3 pressure injury due to neglect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Liliana Moreno, Med-Tech Supervisor/ Administrator and explained the purpose of the visit. The investigation conducted by Department staff consisted of staff interviews, resident interviews and document review.

Evidence shows that on 9/15/2022 a nurse came to the facility to assess R1’s wound on the coccyx which was assessed as a stage 2. The nurse recommended home health care for the wound and the plan was to keep the wound clean, reposition every 2 hours, apply ointment, and dress. On 10/5/2022 the first visit was made by Home Health Registered Nurse (RN1) for wound care and nurse observed the wound was not dressed when R1’s wet diaper was changed, and the nurse documented the wound as a stage 3 open wound with no drainage. The LVN checked on R1 3 times a day but did not always look at the wound. Instead, she checked to make sure the caregivers repositioned R1 every 2 hours. The wound went from a stage 2 to a stage 3 from 9/15/2022 – 10/5/2022.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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 3
Control Number 18-AS-20221223121913
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: 04/18/2025
NARRATIVE
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Interviews show staff reported assisting R1 during varies stages of R1 wound treatment. Staff confirmed there were steps in place to reposition R1. However, R1 had a medical condition that caused stiffness, so repositioning was difficult. Staff S2 and S5 indicated they were trained to provide wound care to R1 on the days no skilled nurses were scheduled. The procedure required staff to clean, pat dry, and dress the wound. However, staff never dressed the wound which caused the wound to worsen. Staff only applied ointment, repositioned R1, and attempted to keep R1 dry. There was no documentation of dressing being applied to the wound. In addition, the facility staff did not maintain a chart or log for R1’s plan of care or change of condition as it worsened. The facility only implemented charting changes after R1 condition changed after 12/2022.

Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. An immediate civil penalty is assessed for $500.00, per Health and Safety Code. An additional civil penalty may be imposed per Health and Safety Code 1569.49 (f).
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221223121913
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: 04/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2025
Section Cited
CCR
87466
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87466 The licensee shall ensure residents are regularly observed ..changes in physical, mental, emotional and social... appropriate assistance...bservation reveals unmet needs...changes such as unusual weight gains or losses or deterioration of mental ability..physical health condition are observed..licensee shall ensure that such changes are documented and attention of the resident's physician and the resident's responsible person
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Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Licensee will submit an email and statement of documentation of proof of staff reading over section 87466 and completion of training to LPA Farlow by Plan of Correction (POC) due date.
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Based on the evidence the licensee did not comply with the section cited above by staff not properly caring for R1's wound resulting in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3