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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426760
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:17:00 PM


Document Has Been Signed on 06/06/2022 12:17 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 COURTFACILITY NUMBER:
336426760
ADMINISTRATOR:MARLYA DUNHAMFACILITY TYPE:
740
ADDRESS:161 N HEMET STTELEPHONE:
(951) 927-6817
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:66CENSUS: 33DATE:
06/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marlya Dunham - AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220602163658. During today's inspection, LPA Colvin observed the following deficiency, which was reviewed with Administrator Marlya Dunham:

In LPA Colvin's review of the facility's file prior to coming out to conduct the inspection, LPA Colvin observed that the facility has overdue licensing fees. These fees consist of annual fees for years 2019 - 2021, as well as subsequent late fees for those years. As of today's inspection, the Licensee owes $5,715.60 in overdue licensing fees. Deficiency cited.

Note: Additionally, upon arrival to the facility, LPA Colvin observed signs for the facility under the name "Hacienda Senior Living". LPA Colvin did not note any reference to submission of documents for a name change in Licensing's electronic system, but LPA Colvin was informed by the Administrator that documents had been submitted previously, but there was no further response. LPA Colvin instructed Administrator Marlya Dunham to email the documents to LPA Colvin (name change only) and LPA Colvin will have them processed immediately.

An exit interview was conducted with Administrator Marlya Dunham, and a copy of this report, LIC 809D, and appeal rights was provided.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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 06/06/2022 12:17 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CITRUS COURT
FACILITY NUMBER: 336426760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2022
Section Cited

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Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:
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Based on record review, the Licensee did not comply with the above Health & Safety Code with licensing fees ($5,715.60 total). LPA Colvin observed that the facility past due licensing fees for annual fees as well as late fees for 2019 - 2021. This is an immediate safety risk to residents.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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