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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426760
Report Date: 08/19/2019
Date Signed: 08/19/2019 03:33:46 PM

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:BARBARA BOISTONFACILITY TYPE:
740
ADDRESS:161 N HEMET STTELEPHONE:
(951) 927-6817
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:66CENSUS: 43DATE:
08/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Allison Ortiz, LVNTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Naisha Kendrix arrived to verify the removal of a current employee, Luis Roman and to conduct a case management inspection for further information in a complaint investigation received 3/19/19. LPA met with the Wellness Director, Allison Ortiz. The Administrator, Toni Jackson was in an on-site training during the visit. LPA toured the facility and conducted additional interviews of staff, residents, and family members for the complaint investigation.
A Non-Exemptible Conviction notification letter was generated to notify the licensee and former employee that the employee is not allowed to work or be present in the facility. The employee does not have the necessary criminal record clearance, or an exception required by Title 22 for employees to work in a residential care facility for the elderly (RCFE).
LPA spoke to the Wellness Director at approximately 10:15 AM regarding the removal of the employee. Mrs. Ortiz stated the employee was employed with the facility for approximately three days but did not work directly with residents in care. After the third day employee was terminated due to unrelated performance issues. LPA spoke with two staff members who confirm Luis Roman does not currently work at the facility. LPA provided the Confirmation of Removal Notification letter for a signature to Wellness Director Ortiz.
LPA verified with Mrs. Ortiz and staff that employee is not allowed on the property or to interact with residents of the facility as of today’s inspection. Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500 if needed.

No deficiencies cited during the visit.

An exit interview was conducted where this report was provided to Mrs. Ortiz.

Verification of removal is complete.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Naisha KendrixTELEPHONE: (951) 204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
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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