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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:47:31 PM


Document Has Been Signed on 01/25/2024 04:47 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 ASC, 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:
01/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Medical Technican, TIME COMPLETED:
05:00 PM
NARRATIVE
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On 1/25/2024, Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit for a separate unrelated matter. LPA met with Medical Technican, Judine Ramirez, who was informed of the purpose of the visit.

During the visit, LPA conducted conducted a walk through and conducted records reviews. LPA requested resident records and was informed both individuals with access to the files were not on the premises and could not provide the files to the LPA. A plan of correction was created with the staff and documented on deficiency page. A health and safety check was conducted on the facility residents. No immediate health or safety concerns were observed during the visit.

An exit interview was conducted with Medical Technican, Judine Ramirez, where this report along with appeal rights and deficiency pages were reviewed and provided to them.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 2


Document Has Been Signed on 01/25/2024 04:47 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 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87506(a)

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(a) The licensee shall ensure that a...record is maintained for each resident in the facility or in a central administrative location readily available...to licensing agency staff. This requirment was not met as evidenced by:
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The administrator agreed over the phone to send the documents to the LPA's email by the POC due date.
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Based on interview, the facility did not have file for R1 readily avaible for licensing review. This poses a potential health, saftey 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.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2