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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 09/22/2025
Date Signed: 09/22/2025 11:44:52 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
08/08/2025 and conducted by Evaluator Armando Perez
COMPLAINT CONTROL NUMBER: 18-AS-20250808101937
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: 53DATE:
09/22/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director Valeria Garcia and Administrator Liliana MorenoTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff did not prevent a physical altercation between residents
Staff did not respond to resident's calls for assistance
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 allegations. LPA Perez met with Executive Director Valeria Garcia and Administrator Liliana Moreno where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, and file reviews.

On August 08, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not prevent a physical altercation between residents and staff did not respond to residents’ calls for assistance. It was alleged that on August 1, 2025, Resident 1 (R1) was involved in a physical altercation with R2 and staff failed to respond to verbal and telephone calls for intervention and assistance.

Interview with Additional Witness 1 (AW1) disclosed that R1 observed R2 in the incorrect room and asked R2 to exit the room.
Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
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-20250808101937
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: 09/22/2025
NARRATIVE
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AW1 reported that R2 became agitated and responded with physical aggression towards R1. AW1 reported R1 yelled for staff assistance and called the facility number with no response, leading to calling law enforcement for assistance. Additionally, AW1 reported that the altercation resulted in injuries to R1 and medical transport for both residents.

Interview with Executive Director, Valeria Garcia stated she was made aware of the incident and clarified that NOC staff are assigned to supervise the villas on a rotational basis. Executive Director stated the altercation occurred while staff were actively following protocol during their scheduled rounds. Valeria added that proper assessments, additional care plans, and staff monitoring have been adjusted for R2. Through interviews, 4 of 4 staff reported that they did not observe or hear of the altercation between R1 and R2. Additionally, they did not hear the facility phone ring and were made aware of the altercation when paramedics and law enforcement arrived at the facility.

A review of facility records confirmed that the NOC shift operates from 10:00 PM to 6:00 AM and is staffed with three to four personnel responsible for the care of 54 residents. Through supplemental interviews, it was further corroborated that several residents remain active during these hours, often engaging in mobility throughout the facility. Additional information obtained indicated that frequent calls for assistance are common during NOC shift, which presents ongoing challenges in maintaining adequate supervision and ensuring consistent quality of care under the current staffing levels.

Based on interviews and record reviews, the allegation that staff did not prevent a physical altercation between residents and staff did not respond to resident's calls for assistance 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. The facility will be cited.

An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia, and Administrator Liliana Moreno 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: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250808101937
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: 09/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in 87468.1…elderly shall have …personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs.
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The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care.
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This requirement was not met as evidenced by:
Based on interviews and records review, the facility is not staffed sufficiently at night from 10pm to 6am to meet night supervision needs.
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The staff rotational procedure for supervision and the reported active residents during the night led to an altercation that staff did not witness or intervene. This poses a potential health safety or personal rights risk to residents in care.
Type B
10/13/2025
Section Cited
CCR
87415(a)
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Night Supervision: 87415 (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures… to assist in caring for residents in the event of an emergency. This requirement was not met as evidenced by:
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The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care.
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Based on interviews and record reviews, it was determined that staff failed to assist during an emergency involving a physical altercation between two residents. Staff were unavailable to provide timely intervention, resulting in injuries to both residents.
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 The lack of sufficient overnight supervision from 10:00 p.m. to 6:00 a.m. contributed to the incident occurring without staff presence or response. This poses a potential health safety or personal rights risk to residents in care.
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: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
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