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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 10/17/2025
Date Signed: 10/17/2025 01:09:54 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-20250505091658
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: 52DATE:
10/17/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Executive Director Valeria Garcia and Administrator Liliana MorenoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility does not have adequate staffing to meet resident's care needs.
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 facility does not have adequate staffing to meet resident's care needs. It was alleged that facility only has 3 caregiver staff to supervise five villas, resulting in two villas not staffed and unable to provide proper care and supervision for. Information obtained from interview with Executive Director Valeria Garcia stated that the facility made recent staffing adjustments that are sufficient to meet the care needs of residents. ED noted the facility has increased night shift coverage from three to four caregivers between 10:00 PM and 6:00 AM to enhance supervision and response times.
Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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-20250505091658
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: 10/17/2025
NARRATIVE
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Additionally, ED added staff are now required to conduct resident checks every 10 to 15 minutes throughout the night. Information obtained from interviews with residents stated there were many incidents that required immediate attention and did not receive a response from staff in a timely manner. Further information obtained stated there was an incident where Resident #1 (R1) fell and required staff assistance. The information provided was corroborated by Witness 1 (W1), who stated they activated R1’s call pendant and verbally called out for help. W1 further noted that when staff eventually arrived, they explained the delay was due to assisting another resident with an emergency. Additional information obtained stated there was an incident where a physical altercation occurred between two residents. Staff was requested, but no staff responded. As a result, residents contacted law enforcement for assistance.

Additionally, there were two documented incidents in which medications were not administered due to inadequate staffing. On February 1, 2025, the Night Operations Shift (NOC) lacked an assigned MedTech, resulting in at least two residents missing their scheduled medications, including any Pro Re Nata (PRN) requests. A second occurrence took place on Saturday, April 26, 2025, when an unexpected staff call-out prior to the evening shift, which left the facility without MedTech coverage. As a result, scheduled medications were not dispensed to residents. Interviews with the Executive Director and staff confirmed that attempts were made to secure coverage; however, due to emergencies, existing staff commitments, and the short notice, a qualified replacement could not be arranged for that shift.

A review of the facility’s staffing schedule from January through May 2025, there are three shifts. During this period, the AM and PM shifts consistently maintained six to seven staff members who actively provide resident care, excluding office and kitchen personnel. In contrast, the NOC (overnight) shift, operating from10:00 PM to 6:00 AM, was inconsistently staffed with only three to four caregivers. The NOC shift was responsible for approximately 54 residents. The shortage in staff, compromised both the safety and the level of supervision provided to residents in care. This poses as a potential health & safety risk to residents in care.

Based on interviews and record reviews, the allegation that facility does not have adequate staffing to meet resident's care needs. 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: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250505091658
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: 10/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
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 Section 87468.1…elderly shall have …the following 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 has corrected the issue. On 10/13/25 an updated LIC 500 and Staffing schedule was submitted to satisfy the plan of correction.
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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.
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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: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
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