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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:51:15 AM

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
08/20/2020 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200820153416
FACILITY NAME:CITRUS GARDENSFACILITY NUMBER:
336426759
ADMINISTRATOR:KELLEY LARAFACILITY TYPE:
740
ADDRESS:25911 STANFORD STTELEPHONE:
(951) 925-7107
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:55CENSUS: 54DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Diana Molina-Ramirez, Executive Director and Ashlee Theus Business Office ManagerTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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9
Residents fell while in care.
Resident sustained pressure ulcers while in care.
Resident sustained unexplained bruisinig while in care.
Staff did not provide water to residents.
Staff did not provided resident with their own hygiene supplies.
Staff not meeting residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas met with Executive Director Diana Molina-Ramirez and Business Office Manager Ashlee Theus in the Riverside/San Bernardino Regional Office to deliver findings on the above allegations. Department staff investigated the above allegations, and LPA Nickolas also conducted facility tours, file reviews, and additional interviews pertinent to this investigation.

Allegation #1 “Residents fell while in care”. The allegation alleged that client #1 (C1), a month before this allegation, was made fell with no injuries. The allegation alleged that client #2 (C2) also fell, and their health has declined since their fall. Department staff interview with the reporting party (RP) revealed that they were advised of the fall by other facility staff members, but there is no evidence that the fall occurred on the date(s) advised. The RP also discusses other falls with another client (client #3 [C3]) that was not originally reported. Department staff interview with staff #1 (S1) revealed that C1’s fall was documented. Department staff interview with staff #2 (S2) revealed that S2 acknowledges C1 fell, but the time frame does not match what was originally reported by the RP.
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: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 3
Control Number 18-AS-20200820153416
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: 09/13/2023
NARRATIVE
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Department staff interview with the Executive Director revealed that they are not aware of a fall occurring with C1 around the time frame alleged by the RP. LPA Nickolas was unable to interview C1 because they are deceased. LPA Nickolas' facility file review revealed that the facility's in-house notes document a fall with C1 several months before. LPA Nickolas' file review also revealed that C2 never resided at the facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #2 “Resident sustained pressure ulcers while in care”. The allegation alleged that C1 had bed sores on two (2) areas of their body. The allegation alleged that the stage of the sores was unknown. Department staff interview with S1 revealed that S1 acknowledged the sores, and hospice provided the facility instructions on rotating C1. Department staff interview with the Executive Director revealed that a hospice nurse noted the pressure wounds on July 21, 2020, but it was too early to stage them. The Executive Director stated that the hospice agency advised them that the pressure wounds were healing nicely. LPA Nickolas' interview with C1 revealed they could not be interviewed because they are deceased. LPA Nickolas' file review revealed that C1's hospice agency treated their pressure wounds with wound care specialists and nurses. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3: “Resident sustained unexplained bruising while in care”. The allegation alleged that numerous clients had bruises on their bodies. LPA Nickolas’ interview with the Business Office Manager revealed that although they worked at the facility when this allegation was made, they do not remember. LPA Nickolas’ interview with several clients in care revealed that they could not provide any information about this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #4 "Staff did not provide water to residents". The allegation alleged that clients were observed sitting outside in the heat, and there was no water or cups for clients to have water. LPA Nickolas' interview with the Business Office Manager revealed that they denied this allegation. LPA Nickolas interviewed several clients in care. However, the clients interviewed were unable to provide answers to questions asked about this allegation. LPA Nickolas observed pitchers of ice water and cups outside when clients were outside and in the common areas of all five (5) Villas. LPA Nickolas also reviewed the facility's hydration policy and confirmed that the facility's staff are trained according to the hydration policy. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200820153416
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: 09/13/2023
NARRATIVE
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Allegation #5 “Staff did not provided resident with their own hygiene supplies”. The allegation alleged that the facility staff has one (1) hairbrush for eight (8) residents. The allegation alleged that the Executive Director needed to go and buy supplies. Department staff interview with the Executive Director revealed that the facility cannot order supplies due to billing issues with the vendor. The Executive Director stated that supplies are ordered through the sister company, and the facility had yet to go without supplies. Department staff interview with S2 revealed that the facility is having trouble with the supplier delivering supplies; therefore, the Executive Director is buying supplies. S2 stated the facility has enough supplies to care for residents. Department staff interview with staff #3 (S3) revealed that S3 confirmed the allegation. During a facility tour on August 7, 2023, LPA Nickolas’ observed that the facility has sufficient hygiene supplies to care for the residents in care. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #6 "Staff not meeting resident's needs". The allegation alleged that the facility cannot meet the needs of the clients because they are understaffed. LPA Nickolas' interview with the Wellness Coordinator revealed one (1) caregiver in every Villa, except the largest Villa has two (2) caregivers. LPA Nickolas' interview with the Business Office Manager revealed that although there are assigned caregivers to each Villa, the staff working at the facility is expected to assist the clients when needed. LPA Nickolas' interviews with clients in care revealed that some clients could participate in the interview process while others could not. The clients who participated in the interview expressed no concerns about residing at the facility. LPA Nickolas visited the facility three (3) times and conducted tours during each visit. LPA Nickolas' observed sufficient staffing to meet the client's needs.

A finding of Unsubstantiated means that 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: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3