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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 08/25/2025
Date Signed: 08/25/2025 01:41:02 PM

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
05/05/2025 and conducted by Evaluator Armando Perez
COMPLAINT CONTROL NUMBER: 18-AS-20250505105846
FACILITY NAME:CITRUS GARDENSFACILITY NUMBER:
336426759
ADMINISTRATOR:TRACY LANGENDOENFACILITY TYPE:
740
ADDRESS:25911 STANFORD STTELEPHONE:
(951) 925-7107
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:59CENSUS: 54DATE:
08/25/2025
UNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Executive Director Valeria GarciaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not administer prescribed medications to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and file reviews.

On May 05, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not administer prescribed medications to residents in care. It was alleged that occasionally on the weekends, the facility would not staff a Medical Technician (MedTech) to be scheduled. The inability to cover the shift resulted in medication not being dispensed to residents.

In regards to the allegation, LPA, in collaboration with Executive Director (ED) Valeria Garcia and two of two staff members responsible for employee scheduling, conducted interviews and reviewed documentation including electronic Medication Administration Records (MAR), paper PRN logs, and employee timecards.
Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
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-20250505105846
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: 08/25/2025
NARRATIVE
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A comprehensive review of facility records was conducted and uncovered inconsistencies in the scheduling of Medical Technicians (MedTechs) on the staff calendar. LPA identified 16 instances where MedTech coverage appeared to be missing for at least one shift, prompting concerns regarding the administration of medications. The investigation confirmed that a qualified MedTech was present during 14 of the 16 shifts in question, thereby negate there was inappropriate coverage. Information obtained from an interview with S2, it was determined that abrupt changes were made to the schedule and the staff schedule was not updated. On February 1, 2025, no MedTech was assigned during the Night Operations Shift (NOC), resulting in an estimated two residents not receiving their scheduled medications and any PRN requests by the residents in care. Additionally, on Saturday April 26, 2025, an unexpected staff call-out before the PM shift left the facility without MedTech coverage, leading to a failure in dispensing scheduled medications to the facility residents in care. Interviews with ED and staff members confirmed that efforts were made to secure coverage; however, due to emergencies, pre-existing schedules, and the short notice, a qualified replacement could not be arranged on that Saturday shift.

Based on interviews and record reviews, the allegation that staff did not administer prescribed medications to residents in care is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250505105846
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: 08/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental
Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility…(4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as evidenced by:
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Administrator will provide LPA with a planned procedure in place to properly dispense medication in the case of a call out by a MedTech. The plan must include weekend and NOC shift instructions on how coverage and medication dispensing will be followed.
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Based on observation, interview and record review, Medication was not administered as prescribed by physician, on two of two occasion to residents, which poses a potential health, safety or personal rights risk to residents in care.
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Administrator must provide training on the procedure with management and MedTechs. An email will need to be provided to LPA by POC date.
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3