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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 12/28/2021
Date Signed: 06/02/2023 03:53:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/13/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211213132843
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: 40DATE:
12/28/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elizabeth Torres, Activities Director TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee did not ensure safety of residents through infection control
Facility does not have enough staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility and met with Activities Director Elizabeth and advised the purpose of the visit was to deliver findings for the above allegations. LPA then toured the facility.
It was alleged that a staff member felt ill and was told that they were not allowed to go home. After leaving the same day, the staff member tested positive for COVID-19. It was reported that there were approximately 4 other caregivers to work the shift that day.
Through interviews with staff, LPA discovered that each employee is screened prior to entering the facility. Staff interviews further revealed that management or other staff will cover shifts that may be short for the day.
Interviews with residents were attempted but due to cognitive levels, were not able to be successful.
It was then alleged that an unnamed staff member was sick and was forced to work, and this resulted in the staff member being sick for a week while at work inside the facility. This was investigated, and as a result, LPA found no evidence of the unnamed staff member or incident.
Further, it was stated that although there was enough staff, staff are not covering the 4 villas with enough coverage for the residents. It was alleged that there were 5 staff, but not all 5 staff are to cover the 4 villas. Sometimes 3 staff are utilized. Interviews with staff relayed that the villas are the primary location for all residents in care, and is the only area that staff are utilized with approximately 5 staff covering the villas at all times. When staffing was short, management was routinely stepping up to cover as well.
An exit interview was conducted where a copy of this report was discussed and provided.
This is an amended version of the original report dated December 28, 2021.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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 2
Control Number 18-AS-20211213132843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2021
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.
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Administrator will immediately remove staff from facility, and submit proof of background clearance submission by 12/29/21.

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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: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2