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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426759
Report Date: 07/29/2025
Date Signed: 07/29/2025 02:25:55 PM

Substantiated


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
12/23/2022 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 18-AS-20221223121913
FACILITY NAME:CITRUS GARDENSFACILITY NUMBER:
336426759
ADMINISTRATOR:TRACY LANGENDOENFACILITY TYPE:
740
ADDRESS:25911 STANFORD STTELEPHONE:
(951) 925-7107
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:55CENSUS: 54DATE:
07/29/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Valeria Garcia, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff not regularly providing observations to residents physical changes.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation of and deliver findings to the above mentioned complaint. LPA was greeted and granted entrance into the facility by Jessenia Rubalcaba, Activity Director. Jessenia informed the Administrator of my arrival. LPA later met with Administrator, Valeria Garcia who was informed of the reason for today's visit.

The investigation consisted of interviews with staff, and review of records.

The investigation revealed that on September 15, 2022, Witness three (W3) conducted a physical examination of Resident 1(R1) and noted an acute stage 2 ulcer on the sacral area. The ulcer had been present for 11/12 weeks. The patient care plan was to turn every 2 hours or as needed, change diaper often, continue air mattress, home health for wound care, continue applying skin protectant, and zinc ointment twice a day and as needed, apply nonadherent dressing to area and change twice a day and as needed, and monitor. Although staff reported following the care plan for R1, interviews revealed that facility staff did not document written observation of R1 change in condition. ***Continued on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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 3
Control Number 18-AS-20221223121913
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 GARDENS
FACILITY NUMBER: 336426759
VISIT DATE: 07/29/2025
NARRATIVE
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Interviews with S2, S3, and S5 reported providing verbal communication to staff on changes of condition and new procedures. It was reported after R1 conditioned worsen staff started a daily log or charting changes in R1 condition. This new procedure required caregiver to chart resident’s daily activities or behaviors such as showers, food intake, bowel movements, behaviors, complete a shower check list, and skin condition. It was found that R1 was diagnosed with Stage 1 pressure injury and required assistance with all daily living activities. There was no charting or log to identify changes in R1 condition.

Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20221223121913
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 GARDENS
FACILITY NUMBER: 336426759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87463(1)(E)
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87463(1)(E) ReappraisalsSignificant changes in condition, as...Definitions, include,...limited, (E)Illness or injury...ignificant change in the health care or dietary needs of the resident.
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Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Administrator will submit an email with a statement knowledging the regulation cited.Proof of staff reading over section 87463(1)(E) and completion of training to LPA Farlow by Plan of Correction (POC) due date.
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Based on the evidence the Administrator did not comply with the section cited above by staff not properly reporting, observing and or documenting the changes in R1's condition which resuled in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons 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: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3