331880924-11-21-2024-18-AS-SSAS-DCH2CT-20241231161716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880924
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:01:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2024 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240507140146

FACILITY NAME:	CITRUS PLACE		FACILITY NUMBER:	331880924
ADMINISTRATOR:	VICKY TORRES		FACILITY TYPE:	740
ADDRESS:	7898 CALIFORNIA AVENUE		TELEPHONE:	(951) 687-2241
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	140	CENSUS: 117	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Vicky Torres		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff are not following food safety protocols.
Staff are falsifying medical documentation regarding residents in care.
Staff are not reporting incidents involving residents in care.
Staff are administering crushed medication(s) to resident(s) in care without physician(s)' permission.
Staff are not reassessing residents as necessary.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Joseph Alejandre and Kimberly Lyman made an unannounced visit to deliver the findings for the complaint investigation for the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. The investigation into the allegation, staff are not following food safety protocols, revealed the following. LPA toured the kitchen with the Executive Chef. LPA observed the kitchen is clean and organized. LPA observed the refrigerator is kept at 37.0 degrees Fahrenheit and the freezer was at 0.0 degrees Fahrenheit. LPA observed a 2-day perishable and a 7-day non-perishable food supply on hand in the kitchen. The Executive Chef reported that food is delivered 3 times a week and fresh food is always used to prepare all meals. The Executive Chef reported that standard restaurant practices are used, and all food is prepared properly for the safety and enjoyment of the residents. LPA interviewed 4 kitchen staff. 4 out of 4 kitchen staff reported that they always follow kitchen procedures to ensure all food preparation is safe. 4 out of 4 staff reported that only kitchen staff with a food handler’s card are allowed to prepare food.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240507140146

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS PLACE	FACILITY NUMBER: 331880924
	VISIT DATE: 11/21/2024

NARRATIVE

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4 out of 4 staff interviewed reported that caregivers will serve trays to residents but are not involved in food preparation. 4 out of 4 caregivers interviewed reported they have served trays to residents and are not involved in the preparation of food. LPA observed breakfast and lunch being served. Food is prepared in the kitchen and brought to the assisted living and memory care. Food is placed in serving warmers and then served to residents by kitchen staff. LPA reviewed facility records and all kitchen staff have valid food handler cards. 6 out of 6 residents interviewed reported that they have no issues with the food and have never been sick because of the food at the facility. LPA did not observe any health and safety concerns during the visit. The facility kitchen was inspected by Riverside County Environmental Services on March 13, 2024 and received a score of 96 out of 100. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation, staff are falsifying medical documentation regarding residents in care, the investigation revealed the following. LPA reviewed 6 resident files, including physician reports and needs and service plans. LPA did not observe any evidence of records being falsified. LPA observed all 6 files reviewed had a current needs and service plan. LPA interviewed 5 staff members. 5 out of 5 staff members reported that they have never falsified records and have no knowledge of anyone falsifying any records. LPA observed no violations regarding residents’ physician reports or needs and service plans (re-appraisals). LPA reviewed 6 resident medications and medication administration records (MARs). No discrepancies observed. None of the evidence gathered corroborates the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff are not reporting incidents involving residents in care, revealed the following. No specific details were provided about incidents not being reported. LPA reviewed multiple incident reports sent to the Agency.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240507140146

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITRUS PLACE	FACILITY NUMBER: 331880924
	VISIT DATE: 11/21/2024

NARRATIVE

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The Executive Director reported that all resident incidents, including falls are reported. 5 out of 5 staff interviewed reported all incidents involving residents are reported to management, reviewed, and sent to the Agency. There is no evidence to corroborate the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff are administering crushed medications to residents in care without physicians' permission, revealed the following. A review of resident records shows, 9 residents have physician’s orders for medication to be crushed. LPA interviewed 5 staff members. 5 out of 5 members reported they only crush medication when there is an order from the physician to do so. 5 out of 5 staff members reported that they have never witnessed anyone crushing medication for a resident without an order. 5 out of 5 residents interviewed reported that their medication is not crushed and is administered as prescribed. LPA reviewed 6 resident medications and medication administration records (MARs). No discrepancies observed. None of the evidence gathered corroborates the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation, staff are not reassessing residents as necessary, the investigation revealed the following. LPA interviewed 5 staff members. 5 out of 5 staff members reported that residents are reassessed every 6 months or when there is a change in condition or upon return from a hospital stay. Staff reported the director of nursing completes the assessments every 6 months. LPA reviewed 6 resident files. All 6 residents had a current needs and care plan (re-appraisal). The Executive Director reported that after the needs and care plan is updated they arrange for a meeting with the responsible party to discuss the new care plan and to have it signed. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report of the report provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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