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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 04/12/2021
Date Signed: 07/16/2021 01:54:06 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/15/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201015161158
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: 29DATE:
04/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shannon HundleyTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Uncleared adult working in facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to deliver findings for the above allegation. LPA contacted the facility via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Administrator, Shannon Hundley. The investigation consisted of interviews with staff/residents and records review.

LPA reviewed records of Staff #1's (S1's) file in which it was confirmed that S1 had worked at the facility from 09/2020 to 01/2021. LPA reviewed the Licensing Information System (LIS) which indicated that (S1) had background clearance and was associated to several other facilities; however, S1 was not listed on the personnel roster for Citrus Gardens as of 10/20/2020. LPA interviewed Staff #2 (S2) who stated that an LIC 9182, LIC 508, and a copy of S1's Identification Card was sent to the Department. LPA interviewed Staff #3 (S3) who stated that all Criminal Background Clearance Transfer Request documents were in S1's file but could not confirm if they were sent to the Department.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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-20201015161158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759
VISIT DATE: 04/12/2021
NARRATIVE
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Based on evidence obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning 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 where this report (LIC 9099) was discussed and a copy was provided to Hundley via email.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2