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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:37:23 PM


Document Has Been Signed on 07/25/2023 12:37 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 AC/SC, 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: 53DATE:
07/25/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Assistant Diana Molina Ramirez TIME COMPLETED:
12:45 PM
NARRATIVE
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On 7/25/2023 at 9:15 a.m., Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Executive Assistant Diana Molina Ramirez who was informed of the purpose of the visit. LPA toured the facility’s interior and exterior. The facility is approved for 55 non-ambulatory residents of which five (5) may be bedridden and has a hospice waiver for 25. Executive Assistant Ramirez stated the facility currently has 18 residents on hospice and one (1) bedridden.

During the tour, LPA observed the facility has a small common area in each villa. The outside area provides shaded seating available for resident use. LPA observed residents playing bingo on the patio with Activities Director Elizabeth Torres. Indoor and outdoor passageways are free of obstruction. LPA observed fire alarm systems, carbon monoxide detectors and fire extinguishers throughout the villas. Long-Term Care Ombudsman posters were observed throughout the facility as well. The temperature in each villa is comfortably set to 72 degrees Fahrenheit. There are no bodies of water on the premises. LPA toured the kitchen and observed food was stored in a safe and healthful manner. Facility met Departmental requirements for 2-day perishables and 7-day non-perishable food items. Medications are secured in medication carts inside the locked med room. Cleaning solutions and chemicals are secured in a locked hallway closet. Knives and sharp instruments are secured in the kitchen.

Continued on LIC809-C..
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 07/25/2023 12:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to LPA observing blood in toilet and feces on toilet seat in Villa #1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Facility agreed to provide staff training regarding infection control practices and precautions. Proof of correction to be submitted to CCLD by close of business on POC due date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to the water damage and leakage in Villa #1's restroom in front of room 102, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Facility agreed to contact maintenance person to make necessary repairs to stop water damage/leakage in Villa #1 restroom in front of room 102. Facility stated restroom shower will not be used until repairs are made. Proof of correction to be submitted to CCLD by POC due date.
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: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2023 12:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to Staff #1 (S1) not having first aid/CPR training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Facility agreed to submit proof of S1's first aid/CPR training to CCLD by close of business on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
VISIT DATE: 07/25/2023
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Based on observation and record review, LPA cited the following deficiencies faulting the facility:

During the tour of Villa #1, LPA observed the restroom toilet in front of room 104 had blood inside of the toilet and feces on the toilet seat. Executive Assistant Ramirez asked staff to clean the restroom. LPA also observed Villa #1’s restroom in front of room 102 has water damage on the base molding between the toilet and shower area. Executive Assistant Ramirez confirmed water damage on base molding and stated water comes out of the base molding area, and maintenance person was contacted to make the repairs. Executive Assistant Ramirez added that the facility is in the process of renovating all restrooms. During random staff record review, LPA observed Staff #1 does not have CPR/First Aid training.

A copy of this report was discussed and provided to Executive Assistant Ramirez along with LIC809-D and Appeals Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4