Citrus Place

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not observe residents for change in condition

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Connections for Living Director Megan Snell, and explained both the purpose of the visit and the details of the allegation. On January 24, 2025, Community Care Licensing Division (CCLD) received a complaint that facility staff do not observe residents for change in condition. It was alleged that R1 and R2 were experiencing cognitive decline and facility staff did not address their change in condition. According to Additional Witness 1 (AW1), both R1 and R2 were permitted to leave the community unsupervised when they should have been placed in a higher level of care. AW1 acknowledged reporting their concerns to management. Information from an interview with ED, stated that R1 and R2 resided in Independent Living and were not Assisted Living residents. A review of facility records, including resident rosters, dthe state’s words, verbatim · CDSS document, Apr 2, 2026 · control 18-AS-20250124100551

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not give resident medication as prescribed

On 3/4/25, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to investigate the allegation listed above. LPA met with Administrator, Vicky Torres who who was informed of the purpose of the visit. It was alleged staff mismanaged Resident 1's (R1's) medication resulting in their hospitalization. LPA toured the facility, conducted interviews, and obtained copies of pertinent records. LPA reviewed R1's admission agreement dated 11/6/23 and section 14 notes medication will be monitored as prescribed by the Resident's doctor. LPA reviewed R1's Physician's Report for Residential Care Facilities for the Elderly dated 11/17/23 noting R1 does not have the capacity to store or administer their own prescription medications. LPA reviewed R1's assessment dated 1/9/25 noting R1 requires total assistance with medications. Administrator Torres was interviewed and reported when residents return from the hospital, the facility faxes the updated physician orders to tthe state’s words, verbatim · CDSS document, Mar 4, 2025 · control 18-AS-20250225135432

Allegation investigated: Staff did not seek timely medical care for resident

Licensing Program Analyst, (LPA) Armando Perez, conducted an unannounced visit to the facility and met with Connections for living Director, Megan Snell. The purpose of the visit was to inform of the complaint allegation findings regarding the listed allegation. During this investigation, LPA conducted interviews with Administration, staff, clients, and additional witnesses. LPA also obtained pertinent documentation in order to assist with determining the findings. On December 2, 2024, Community Care Licensing (CCL) received a complaint alleging that facility staff did not seek timely medical care for resident. It was reported that facility staff failed to transport Client 1 (C1) to the hospital for evaluation after an injury was observed. Additionally, it was stated the injury was acknowledged during the morning shift and the facility did not seek medical attention until the afternoon. Information obtained from interviews with Administrator stated facility staff observed swelling to Cthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 18-AS-20241202144300

Allegation investigated: Staff failed to refill resident's medication

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration record (MAR). Regarding the allegation that staff failed to refill resident's medication, the investigation revealed the following: Per MAR, Resident 1 (R1) did not receive Tamulosin HCL on 01/16-01/19/2022 and on 01/31/2022 pending delivery of the medication. Facility staff indicated R1's medications are serviced through the VA pharmacy and facilitated by the resident's family member. Witness indicates facility failed to provide adequate notice when refills were due. Facility documentation on 01/12/2022 shows that the family member had visited the facility and medithe state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20220204163100

Allegation investigated: Staff are not providing adequate supervision to residents Staff left resident on the floor for an extended period of time Staff does not administer resident's medications as prescribed

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as incident reports. Regarding the allegations that staff are not providing adequate supervision to residents, staff does not administer resident's medications as prescribed and staff left resident on the floor for an extended period of time, the investigation revealed the following: Facility schedule indicates four caregivers and a med tech for 1st and 2nd shifts and two caregivers/ one med tech for the NOC shift. Nine out of nine staff state scheduling is adequate and staff are able to provide resident care including toileting, showering and assistance with eating. LPA observed residents beithe state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20240429160126

Allegation investigated: 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.

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 whothe state’s words, verbatim · CDSS document, Dec 3, 2024 · control 18-AS-20211020123858

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee is not ensuring that staff are sufficient in numbers, qualifications, and competency to meet residents' needs. Staff yell at residents in care. Staff are being discouraged from reporting incidents involving residents in care.

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility schedule. Regarding the allegations that licensee is not ensuring that staff are sufficient in numbers, qualifications, and competency to meet residents' needs, staff yell at residents in care and staff are being discouraged from reporting incidents involving residents in care, the investigation revealed the following: Facility schedule indicates Memory Care runs four caregivers and a med tech for 1st and 2nd shift and two caregivers/ one med tech for NOC shift. Seven out of nine staff interviewed state facility staffing levels are good and resident needsthe state’s words, verbatim · CDSS document, Nov 23, 2024 · control 18-AS-20240510123439

Allegation investigated: Staff did not prevent resident from pushing another resident

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the investigation, the department toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician reports. Regarding the allegation that staff did not prevent resident from pushing another resident, the investigation revealed the following: On 04/13/2024, Resident 1 (R1) was being escorted back to the resident's room when R2 entered the room and became agitated. R2 pushed R1 and R1 fell and hit the head. R1 was transported to the hospital via 911 and returned with no new findings. Both residents are diagnosed with Dementia and denied the altercation occurred. Staff interviewed confirmed being present when the altercation occurred. Based on interviews conduthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 18-AS-20240415154217

Allegation investigated: 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.

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 ofthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 18-AS-20240507140146

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident's ceiling is in disrepair Resident's electricity is in disrepair

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA s were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility emails. Regarding the allegations that resident's electricity is in disrepair and resident's ceiling is in disrepair, the investigation revealed the following: Resident 1 (R1) had a leak in the ceiling of the living room of the resident's apartment. Facility documentation indicated an ongoing issue with leaks with the initial leak in October 2021. A new leak occurred in December 2021 and facility documentation shows facility was taking steps to address the leak. Executive Director at time of complaint indicated an issue with water in light switches resultthe state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20211215084528

Allegation investigated: Facility staff are not ensuring that resident is adequately fed while in care

Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA s were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as meal tracking form. Regarding the allegation that facility staff are not ensuring that resident is adequately fed while in care, the investigation revealed the following: LPA reviewed meal tracking form during investigation which revealed the resident was on a meal plan. Meal plan indicates Resident 1 (R1) receives three meal trays per day. R1 did not go to the dining room and preferred to eat meals in the room. Two out of two staff indicate with encouragement the resident would come to the dining room. Staff state the resident was being provided meals. Staff indicate assistingthe state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20230411105405

Allegation investigated: Facility is not serving meals in a timely manner. Facility is overcooking the residents food. Facility serving food to residents that is not of quality. Facility does not ensure that an adequate amount of food is available to residents.

Licensing Program Analysts (LPAs) Joseph Alejandre and Kimberly Lyman made an unannounced visit to continue the investigation into the allegations listed above. LPAs met with Executive Director Vicky Torres and explained the reason for the visit. LPAs interviewed the Executive Director and staff and residents. LPAs and the Executive Director toured the facility. The investigation into the allegation, facility is not serving meals in a timely manner revealed the following. LPA was at the facility and observed breakfast and lunch being served on November 19, 2024. It was alleged that residents wait up to an hour before being served. LPA observed 12 residents having breakfast. 6 residents interviewed during breakfast reported receiving their food within 10 minutes of ordering. 4 out of 4 staff interviewed reported residents in the dining room in assisted living receive their food within 5 to 15 minutes of ordering. LPA observed 31 residents having lunch. LPA observed that residents were sthe state’s words, verbatim · CDSS document, Nov 19, 2024 · control 18-AS-20230621124927

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Personal Rights

On August 14, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to initiate the investigation into the listed allegation pertaining to Personal Rights and met with Business Office Manager and explained the purpose of the visit. During today's visit, LPA toured the facility, along with Nina Guzman and requested and received copies of pertinent documents related to Resident #1(R1). LPA was informed that R1 does not reside at the listed facility but resides at the Independent Community (Manor). Due to Community Care Licensing not having jurisdiction over the listed facility this the allegation has been deemed "UNFOUNDED." Based on interviews, record reviews, and observations the allegation finding has been deemed "Unfounded." An allegation finding of "unfounded," means the allegation was without merit or is false and could not have happened and/or is without a reasonable basis. There were No health and safety concerns observed during today's visit. An exit interviewthe state’s words, verbatim · CDSS document, Aug 14, 2024 · control 18-AS-20240813130615

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.