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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880924
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:13:25 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
10/20/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211020123858
FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 111DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Vicky TorresTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Resident was left in soiled diapers/clothing for an extended period of time.
Resident was not treated with dignity and respect.
Resident's toileting needs were not being met.
INVESTIGATION FINDINGS:
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LPAs Joseph Alejandre and Kimberly Lyman made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. The investigation into the allegation, resident was left in soiled diapers/clothing for an extended period of time, revealed the following. W1 reported that on August 22, 2020, when they visited R1 they were wearing 2 diapers and they were soiled. LPA interviewed 2 staff who worked at the time R1 lived at the facility. Both staff reported that R1 was never put in 2 diapers and all residents were changed regularly. W1 reported that R1 was left soiled for long periods of time but did not provide any other dates when this took place. R1 could not be interviewed because they passed away in 2022. The former Executive Director reported that they were unaware of any residents that were left soiled for long periods of time. LPA interviewed 3 residents who reported they had no issues with incontinence care. Based on the evidence gathered the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 18-AS-20211020123858
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: 12/03/2024
NARRATIVE
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Regarding the allegation, Resident was not treated with dignity and respect, the investigation revealed the following. W1 reported that R1 was put to bed without being fully dressed. W1 reported that R1 was put to bed with a top but no bottoms. R1 passed away in 2022 and could not be interviewed. LPA interviewed 2 staff members who worked at the facility at the time R1 resided at the facility. Both staff members reported that none of the residents were ever put to bed with only a top on. LPA interviewed the former Executive Director who reported they were unaware of any reports about residents being put to bed without clothing. Based on the evidence gathered the allegation is unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, Resident's toileting needs were not being met, revealed the following. It was reported that R1 was not assisted with incontinence care. W1 reported that on that on August 22, 2020, when they visited R1 they were wearing 2 diapers and they were soiled. LPA interviewed 2 staff members who worked at the facility when R1 was residing at the facility. Both staff members reported that R1 was always assisted timely with incontinence care. Both staff members reported they did not recall any resident ever having 2 diapers put on them. The former Executive Director did not recall any issues with any of the residents having issues with incontinence care. Based on the evidence gathered the allegation is unsubstantiated meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/20/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211020123858

FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR:SPENCER, LORIFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:140CENSUS: 111DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Vicky TorresTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's hygiene needs were not being met.
Staff did not notify responsible party of resident's change in condition.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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LPAs Joseph Alejandre and Kimberly Lyman made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. The investigation into the allegation, resident's hygiene needs were not being met, revealed the following. It was reported that Resident 1 (R1) was not having their nails trimmed or facial hair removed. Photographic documentation was provided showing R1 with facial hair and untrimmed nails. Witness 1 (W1) reported R1 did not have their nails trimmed regularly and observed R1 with untrimmed nails and facial hair on August 22, 2020. The Administrator reported that the facility policy regarding trimming hair and nails is to assist residents according to their needs. 2 staff members interviewed reported that there is a podiatrist who comes in every other month to trim toenails and staff will trim or shave residents after they receive permission from a resident’s responsible party. W1 reported they were never contacted regarding permission to assist R1 with trimming nails or hair. Both staff members interviewed reported they did not know why R1 would not have their nails or facial hair trimmed. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20211020123858
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: 12/03/2024
NARRATIVE
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Regarding the allegation, staff did not notify responsible party of resident's change in condition, the investigation revealed the following. It was reported that R1 lost a tooth, and the facility did not inform R1’s responsible party. Photographic documentation was provided showing R1 is missing a tooth. Witness 1 (W1) reported visiting R1 on August 22, 2020, and they were missing a tooth. 2 staff members interviewed did not recall when or how R1 lost a tooth. LPA interviewed the former Executive Director (ED) who worked at the facility when the complaint was filed. ED reported they did not remember R1 and did not recall any resident losing a tooth. The preponderance of evidence standard has been met, therefore the allegation is substantiated.

The investigation into the allegation, staff did not safeguard resident's personal belongings, revealed the following. It was reported that R1’s glasses were lost and never found. W1 reported that in September 2020 R1’s glasses were missing along with a picture collage. W1 reported that the Executive Director and staff were notified about the missing items. LPA interviewed 2 staff members and the former Executive Director (ED). Both staff members and the ED did not recall hearing any reports from R1 or their responsible party about any missing items. W1 reported that staff looked for both items but never found anything. W1 reported that they were contacted after R1’s roommate moved out by R1’s roommate’s family and the picture collage was found in R1’s roommate’s closet. W1 reported the picture collage was returned to them in 2022. A review of R1’s file revealed that R1’s file did not have a personal property inventory. LPA interviewed 2 staff members who did not recall R1 losing glasses. W1 does not recall if R1 had their items inventoried. W1 reported they were never provided with a report from the facility concerning the missing items. The facility could not provide any documentation concerning a theft and loss report for R1’s missing items. The former ED at the time the complaint was filed did not recall completing any documentation for R1’s missing items. The facility could not provide an inventory list for R1 or a signed document of R1’s refusal to have their items inventoried. According to CCR 87218(a)(1) the facility is required to complete a personal property inventory for residents. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation, staff did not safeguard resident’s personal belongings is substantiated.

Deficiencies are being cited per Title 22 Division of the California Code of Regulations. An exit interview was conducted and a copy of the report was provided along with appeal rights.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20211020123858
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87464(f)(1)
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(f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by;
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LIcensee agrees to train care staff on CCR 87464 Basic Services and to provide proof of training to LPA.
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Photographic evidence was provided showing R1 with facial hair and untrimmed nails. This poses an immediate health and safety risk to 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20211020123858
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
87211(a)(1)(D)
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Any incident which threatens the welfare, safety or health of any resident...
This requirement was not met as evidenced by;
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Licensee agrees to train staff on CCR 87211 reporting requirements and to submit proof of training to LPA.
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R1 lost a tooth and the responsible party was not notified. This poses a potenational health and safety risk to residents in care.
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Type B
12/17/2024
Section Cited
CCR
87218(a)(1)
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The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement is not being met as evidenced by;
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Licensee agrees to complete an inventory list for each resident and to train staff on CCR 87218. Licensee to forward proof of training to LPA.
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A file review for R1 shows R1 did not have a property inventory list, which poses a potential health and safety risk to 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6