336426759-7-26-2024-18-AS-SMAZ-D7JUN7-20240726154329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:43:35 PM

Document Has Been Signed on 07/26/2024 03:43 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 GARDENS		FACILITY NUMBER:	336426759
ADMINISTRATOR:	TRACY LANGENDOEN		FACILITY TYPE:	740
ADDRESS:	25911 STANFORD ST		TELEPHONE:	(951) 925-7107
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	55	CENSUS: 50	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Diana Ramirez, Onsite Administrator		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Onsite Administrator, Diana Ramirez. She was notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. The interior and exterior areas of the facility were observed to be clean and safe. No pool or body of water was observed on the property. According to the Onsite Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in each building on the property. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Other than seating, each resident bedroom had the required furniture. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The fire panel was inspected and observed to be in a 'normal' status. Several carbon monoxide detectors were tested throughout the facility and found to be operable. LPA observed missing call buttons for multiple resident bedrooms used for the facility's signal system. The LPA observed no signal system device set up for building two. According to staff, it was unknown where the device was moved to. A citation will be issued. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR and

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 07/26/2024

NARRATIVE

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Suspected Abuse training. Hospice Care Plans were observed on file for residents in care. Staff present had the required criminal record clearances. Admission Agreements, Medical Assessments (Physician's Reports), and Service Plans were observed on file for residents in care. Onsite Administrator Ramirez's Administrator's certificate is currently pending review. Administrator Tracy Langendoen has an active Administrator's certificate. The facility currently has 12 residents in care receiving hospice services; which is within their Hospice Waiver limit.

MEDICATION: Two of three medication carts were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be organized, safe, locked, and inaccessible to residents in care. PRN Authorization letters were observed on file. Centrally Stored Medication and Destruction Records were observed on file.

This report was reviewed with Onsite Administrator Ramirez and a copy was provided, along with the LIC 811, LIC 9098 and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2024 03:43 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: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(i)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in one out four buildings that did not have a signal sytem in place. LPA observed call buttons in multiple resident bedrooms used for the facility's signal system to be missing. The LPA observed no signal system device set up for building two. According to staff, it was unknown where the device was moved to. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Onsite Administrator stated a new signal system will be obtained and proof will be submitted by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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