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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005603
Report Date:
10/28/2024
Date Signed:
10/28/2024 10:01:39 AM
Document Has Been Signed on
10/28/2024 10:01 AM
- 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 LIVING
FACILITY NUMBER:
306005603
ADMINISTRATOR/
DIRECTOR:
ITZAYANA BARBA AGUIRRE
FACILITY TYPE:
740
ADDRESS:
142 S PROSPECT ST
TELEPHONE:
(714) 639-3590
CITY:
ORANGE
STATE:
CA
ZIP CODE:
92869
CAPACITY:
95
CENSUS:
82
DATE:
10/28/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:
Charlie Marinko
TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit to the facility for the purpose of following up on citation issued on LIC form 809D on 10/23/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.
*Deficiency cited under Title 22 Regulation 87464(f)(4)) pertaining to Basic Services- Medication has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Alisa Ortiz
LICENSING EVALUATOR NAME
:
Kimberly Lyman
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/28/2024
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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