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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:41:48 PM

Document Has Been Signed on 11/09/2021 02:41 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CITRUS HILLS ASSISTED LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR:TANJA OLANOFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 95CENSUS: 46DATE:
11/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Juan Jorge Poemape, Operations ManagerTIME COMPLETED:
02:48 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted a case management after conducting a 10 day visit for Complaint Control #:22-AS-20211105101618.
On or about 11:33am LPA Quiroz along with Operations Manager (OM) Poemape toured the inside of the facility. While touring left wing hallway, LPA Quiroz observed hole on ceiling cover on left wing of facility on first floor, which was also observed during Annual Required visit conducted on 10/29/2021 and a Technical Violation (LIC 9102) was issued on 10/29/2021. OM Poemape indicated "In the process of hiring new Maintenance Director who will be focusing on physical plant, scheduled to start on November 17th." On or about 11:42am, LPA Quiroz obserbved broken screen door in Room #115 and broken and missing blinds in Room #107. (See attached LIC 809-D)

On today's date, upon LPA Quiroz arriving to facility to conduct 10 day visit for Complaint Control #22-AS-20211105101618, LPA Quiroz was not properly COVID-19 screened. LPA Quiroz observed front desk receptionist assisting residents in hallway, and no staff covering front desk area. A Technical Violation (LIC9102) was issued on 10/29/2021 due to not properly screening LPA Quiroz upon entrance to facility during Annual Required Inspection conducted on 10/29/2021.

Based on today's inspection visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiency.

This report was reviewed with Operations Manager Poemape. A copy of this report, LIC809-D, Appeal Rights were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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 11/09/2021 02:41 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 11/09/2021 at 01:58 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CITRUS HILLS ASSISTED LIVING
FACILITY NUMBER: 306005603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
87303(a)

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87303: Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: CONTINUED BELOW
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Operations Manager agreed to repair crack/hole on left wing hallway ceiling, broken blinds in room#107 and broken sliding door in Room #115 by POC due date of 11/17/2021 and submit proof to CCL by 11/17/2021.
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On or about On or about 11:33am LPA Quiroz along with Operations Manager (OM) Poemape hole on ceiling cover on left wing of facility on first floor, broken screen door in Room #115 and broken and missing blinds in Room #107. This poses a potential risk for residents in care.
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Type B
11/12/2021
Section Cited
CCR87468.1(a)(2)

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87468.1 (a)(2)Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
CONTINUED BELOW
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OM Poemape to ensure all staff working at the facility have received required Personal Rights training and COVID-19 guidance training by POC due date of 11/15/2021 and submit proof to CCL by 11/15/2021.
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This requirement was not met as evidence by: During today's visit, upon LPA Quiroz's arrival, LPA Quiroz was not properly COVID-19 screened at facility entrance. This poses a potential risk for 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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