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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880924
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:50:27 PM

Document Has Been Signed on 12/03/2024 03:50 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CITRUS PLACEFACILITY NUMBER:
331880924
ADMINISTRATOR/
DIRECTOR:		VICKY TORRESFACILITY TYPE:
740
ADDRESS:7898 CALIFORNIA AVENUETELEPHONE:
(951) 687-2241
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 140CENSUS: 111DATE:
12/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Vicky TorresTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced case management visit in conjunction with complaint investigation 18-AS-20240429160126. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPAs interviewed staff and reviewed facility documentation. During the investigation it was revealed that Staff 1(S1) had put the staff's hand over Resident 1's (R1) mouth and told the resident to "Shut up." An investigation was conducted and S1 was terminated from employment at the facility.
LPA observed R1 during the visit. Resident was relaxing in the memory care unit. The resident appeared clean and taken care of.











Based on the observations made during today's visit, the following citation is being cited per California Code of Regulations (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report as well as appeal rights are being provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/03/2024 03:50 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 11/26/2024 at 03:09 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
, 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
87468.1(a)(3)

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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...This req is not met as evidenced by:
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Licensee to provide an in-service on personal rights pertaining to resident abuse and intimidation and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure residents are free from humiliation and intimidation. S1 covered the resident's mouth and told the resident to "Shut up." 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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