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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426759
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:10:25 PM

Document Has Been Signed on 10/21/2021 12:10 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
CCLD Regional Office, 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: 40DATE:
10/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Alyssa Rodriguez, ReceptionistTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20211018132918). During the inspection, LPA observed several deficiencies and the following is a detailed description:.
  • Fire Safety - While touring the facility near R1's bedroom, LPA Gardner observed a door that was able to be unlocked by hand, but then once around the backside of the door, noticed that it was secured with two screws preventing it from opening. Deficiency cited.
  • Personnel Requirements - General- Upon looking through records, LPA did not find an emergency intervention plan to annotate what employees need to do when a residents leaves the facility unannounced. Deficiency cited.
  • Personnel Requirements - General- LPA noted that on the facility schedule at the time of the incident, there was no staff working the building where R1 was housed. Deficiency cited.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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Document Has Been Signed on 10/21/2021 12:10 PM - It Cannot Be Edited


Created By: Jesse Gardner On 10/21/2021 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87203

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Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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This deficiency was corrected at time of visit. The screws were removed, and a new number code lock was installed.
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This requirement was not being met as evidenced by: LPA Gardner observed two screws securing the door shut. This poses an immediate health and safety risk to residents in care.
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Type A
11/05/2021
Section Cited
CCR87411(a)

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Personnel Requirements - Facility personnel shall at all times be sufficient in numbers.... Additional staff shall be employed as necessary to perform.. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services...
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Licensee will submit staff schedule for next 30 days, and submit statement of understanding that staff has read and understand regulation 87411(a) and will comply
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This requirement was not being met as evidenced by: LPA Gardner the staffing schedule on the dates for the two incidents and found staffing was absent in the area of the incident. This poses an immediate health and safety 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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2021 12:10 PM - It Cannot Be Edited


Created By: Jesse Gardner On 10/21/2021 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS GARDENS
FACILITY NUMBER: 336426759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited
CCR
87411(d)(3)

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All personnel shall be given on the job training or have related experience in the job assigned to them.
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
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Licensee to provide training of staff and update the Emergency Intervention Plan to include a section on what staff needs to do when a resident leaves the facility on their own and submit by email to LPA by 11/4/21.
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This requirement was not being met as evidenced by: During a review of records, LPA did not observe any Emergency Intervention training for staff when a resident leaves the facility. This poses an potential health and safety 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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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