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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 09/06/2023
Date Signed: 09/06/2023 02:43:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2022 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220503163805
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: 54DATE:
09/06/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Diana Molina-Ramirez, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained multiple falls at the facility while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Business Office Manager Ashlee Theus and explained the purpose of the visit. The Exective Director Diana Molina-Ramirez, later arrived at the facility.The investigation included facility tours, file reviews, and interviews with relevant parties.

The allegation alleged that client #1 (C1) has had three (3) falls within a six (6) months span of time while residing at the facility. LPA Nickolas's interview with staff #1 (S1) revealed that they were familiar with C1 but unfamiliar with C1's three (3) falls within a six (6) months period. LPA Nickolas' interview with staff #2 (S2) revealed that they could not provide any information about C1's falls within six (6) months. S2 stated that C1 would rock back and forth while in bed. LPA Nickolas' interview with staff #3 (S3) revealed that S3 was an assigned caregiver to C1. S3 stated that C1 liked to do things on their own instead of waiting for assistance but could not provide any details about the circumstances of this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
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-20220503163805
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
VISIT DATE: 09/06/2023
NARRATIVE
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LPA Nickolas’ was unable to interview C1 because they are deceased. LPA Nickolas’ review of C1’s facility file showed that C1's pre-admission/admission documents noted them as a fall risk. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2