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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005603
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:26:39 PM

Document Has Been Signed on 11/20/2024 04:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CITRUS HILLS ASSISTED LIVINGFACILITY NUMBER:
306005603
ADMINISTRATOR/
DIRECTOR:		ITZAYANA BARBA AGUIRREFACILITY TYPE:
740
ADDRESS:142 S PROSPECT STTELEPHONE:
(714) 639-3590
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 95CENSUS: 82DATE:
11/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive DIrector Charlie MarinkoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to conduct and initial investigation on complaint investigation #22-AS-20241114102450. LPAs met with Executive Director (ED) Charlie Marinko and explained the purpose for the visit. During the inspection visit, LPAs noted the following deficiency not related to complaint investigation.

During a tour of the physical plant, LPAs inspected resident room 105. LPAs observed that the closet doors in resident room 105 were dismantled and not in their appropriate position.

Based on the observations made during today's visit, there is 1 Type B deficiency being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Charlie Marinko. A copy of the report and Appeals Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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Document Has Been Signed on 11/20/2024 04:26 PM - It Cannot Be Edited


Created By: Brandon Lopez On 11/20/2024 at 03:23 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: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
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 the provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director (ED) Charlie Marinko stated he will repair or replace the closet doors in resident room 105 by POC due date. ED will email LPA Saborit-Guasch a photo of the closet doors once they have been replaced or repaired.
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This requirement was not met as evidenced by: During a tour of the physical plant, LPAs inspected resident room 105. LPAs observed that the closet doors in resident room 105 were dismantled and not in their appropriate position. This poses a potential health and safety risk to resident 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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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