374601240-7-27-2023-18-AS-CGOH-CU3MWE-20230725095810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601240
Report Date: 07/07/2023
Date Signed: 07/27/2023 12:21:50 PM

Document Has Been Signed on 07/27/2023 12:21 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CITRUS GARDEN RESIDENTIAL CARE		FACILITY NUMBER:	374601240
ADMINISTRATOR:	BRECK ALLEN		FACILITY TYPE:	740
ADDRESS:	704 VIA LADERA		TELEPHONE:	(760) 739-1061
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	6	CENSUS: 5	DATE:	07/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Annie Allen		TIME COMPLETED:	12:09 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) Cheryl Goodrich conducted an unannounced annual visit. LPA met with the caregiver Elizabeth OLeary at the front door and was granted entry. Licensee Annie Allen arrived during the visit. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents. Three (3) residents are on hospice. Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; facility temperature read at 73 degrees; residents' main restroom water temperature read at 102.8 degrees; there were no bodies of water on premises; there was sufficient lighting and mattress pads in all of the residents' bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. Facility does not house firearms and/or ammunition on grounds. Cleaning supplies was stored outside in a locked shed. Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS GARDEN RESIDENTIAL CARE	FACILITY NUMBER: 374601240
	VISIT DATE: 07/07/2023

NARRATIVE

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Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Licensee has completed a written admission agreement, current medical assessment and needs and service plan with each resident. All required postings were posted throughout the facility, facility medication/PRN logs were reviewed and residents’ medications were inspected for dispensing according to physician’s orders. Exceptions & waivers are in place and meet said terms. Licensee handles no resident cash resources.
Items reviewed/discussed: Staff member Aurora Flores is pending a fingerprint clearance. Facility, staff and residents’ records were reviewed. There is no fire evidence of fire drills being conducted at the facility. The Administrator stated they have not conducted fire drills since COVID. Administrator Certificate is current and will expire on 10/25/23 however the Administrator has not received a copy of her certificate from the agency. The Administrator was able to provide proof of courses taken and proof of mailed documents.
Summary: Deficiencies are being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098 01/16) along with a copy of this report was provided to licensee Annie Allen and her signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2023 12:21 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS GARDEN RESIDENTIAL CARE	FACILITY NUMBER: 374601240
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of fire drill records from 2021 and the testimony of the Administrator, the licensee did not comply with the section cited above in 2 out of 2 quarterly drills, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	The Administrator agrees to comply with Health and Safety Codes by completing fire drills quarterly and will continue to conduct fire drills where all staff are present.

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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