Citrus Gardens

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.

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.

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.

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 ensure resident had adequate sleeping accommodations. Facility’s Administrator is not on the premises a sufficient number of hours.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Valeria Garcia and Business Office Manager Judine Ramirez, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses and file reviews. On June 4, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not ensure resident had adequate sleeping accommodation and Facility’s Administrator is not on the premises a sufficient number of hours. In response to concerns regarding inadequate sleeping accommodation, it was reported that a resident had been observed sleeping on a broken bed and staff failed to take corrective action.Interview with ED stated that no reports of a broken bed had been brought to their attention. Cpntinued on LIC 9099-C. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 23, 2025 · control 18-AS-20250604100237

Allegation investigated: Staff are abusive to resident in care.

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 Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff, witnesses and file reviews. On April 10, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility staff are abusive to resident in care. It was alleged that Resident 1 (R1) was being mistreated by staff and experiencing abusive behavior due to nonpayment of rent. Interview with Executive Director, Valeria Garcia, revealed that R1 was unable to pay their rent, but eviction proceedings had not been initiated. It was also stated that R1 had not made any allegations to management of staff abuse. Interview with 2 of 2 staff corroborated that they neither heard R1 report any abuse by staff nor witnessed any stathe state’s words, verbatim · CDSS document, Oct 17, 2025 · control 18-AS-20250410091938

Allegation investigated: Facility does not have adequate staffing to meet resident's care needs.

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 Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and file reviews. On May 05, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility does not have adequate staffing to meet resident's care needs. It was alleged that facility only has 3 caregiver staff to supervise five villas, resulting in two villas not staffed and unable to provide proper care and supervision for. Information obtained from interview with Executive Director Valeria Garcia stated that the facility made recent staffing adjustments that are sufficient to meet the care needs of residents. ED noted the facility has increased night shift coverage from three to four caregivers between 10:00the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 18-AS-20250505091658

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 prevent a physical altercation between residents Staff did not respond to resident's calls for assistance

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Valeria Garcia and Administrator Liliana Moreno where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, and file reviews. On August 08, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not prevent a physical altercation between residents and staff did not respond to residents’ calls for assistance. It was alleged that on August 1, 2025, Resident 1 (R1) was involved in a physical altercation with R2 and staff failed to respond to verbal and telephone calls for intervention and assistance. Interview with Additional Witness 1 (AW1) disclosed that R1 observed R2 in the incorrect room and asked R2 to exit the room. Continued on LIC 9099-C. Substantiatedthe state’s words, verbatim · CDSS document, Sep 22, 2025 · control 18-AS-20250808101937

Allegation investigated: Staff do not prevent resident to resident altercations while in care. Staff did not properly report incidents involving the residents.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director (ED), Valeria Garcia and Administrator Liliana Moreno where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, and file reviews. On March 04, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not properly report incidents involving residents and staff do not prevent resident to resident altercations while in care. It was alleged that between January and March 2025, multiple resident on resident altercations were not reported to Long Term Care Ombudsman Program (LTCO), in accordance with the guidelines outlined in California Assembly Bill 1411 and Title 22 regulations. Additionally it was noted that staff was not preventing resident to resident altercatithe state’s words, verbatim · CDSS document, Aug 29, 2025 · control 18-AS-20250304094204

Allegation investigated: Staff did not administer prescribed medications to residents in care.

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 Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and file reviews. On May 05, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not administer prescribed medications to residents in care. It was alleged that occasionally on the weekends, the facility would not staff a Medical Technician (MedTech) to be scheduled. The inability to cover the shift resulted in medication not being dispensed to residents. In regards to the allegation, LPA, in collaboration with Executive Director (ED) Valeria Garcia and two of two staff members responsible for employee scheduling, conducted interviews and reviewed documentation including electronic Medication Administhe state’s words, verbatim · CDSS document, Aug 25, 2025 · control 18-AS-20250505105846

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: Facility staff not regularly providing observations to residents physical changes.

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 daythe state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20221223121913

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 developed a Stage 3 pressure injury due to neglect.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Liliana Moreno, Med-Tech Supervisor/ Administrator and explained the purpose of the visit. The investigation conducted by Department staff consisted of staff interviews, resident interviews and document review. Evidence shows that on 9/15/2022 a nurse came to the facility to assess R1’s wound on the coccyx which was assessed as a stage 2. The nurse recommended home health care for the wound and the plan was to keep the wound clean, reposition every 2 hours, apply ointment, and dress. On 10/5/2022 the first visit was made by Home Health Registered Nurse (RN1) for wound care and nurse observed the wound was not dressed when R1’s wet diaper was changed, and the nurse documented the wound as a stage 3 open wound with no drainage. The LVN checked on R1 3 times a day but did not always look at the wound. Instead, she checked to make sure the caregivethe state’s words, verbatim · CDSS document, Apr 18, 2025 · control 18-AS-20221223121913

Allegation investigated: Staff threatened resident.

Licensing Program Analyst (LPA) Armando Perez conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Executive Director Valeria Garcia and explained the purpose of the visit and the details of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On February 14, 2025, Community Care Licensing received a complaint alleging that a staff member threatened a resident in care. It was reported that Staff 1 (S1) verbally threatened Client 1 (C1) and Client 2 (C2), stating that the facility was their home and the clients would be evicted if they did not follow the rules. Information obtained from interview with Executive Director, (ED) Valeria Garcia stated that she was made aware of the incident and conducted an internal investigation with the alleged staff and residents involved. ED stated the investigation did not find evidence that S1 made the allethe state’s words, verbatim · CDSS document, Apr 3, 2025 · control 18-AS-20250214110735

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: Facility doesn't have a qualified administrator.

Licensing Program Analysts (LPAs) Javina George and Ferrer Sabarias made an unannounced visit to deliver findings for the allegation listed above. LPAs met with Administrator Valeria Garcia where LPAs explained the purpose of the visit and the elements of allegation. The Allegation was investigated, the investigation consisted of observations, interviews, records review. On 11/06/2024 Community Care Licensing received a complaint alleging that the facility doesn't have a qualified administrator, as they do not possess a valid administrator certificate. Per an interview conducted with Valeria Garcia, whom confirmed that she has been the Administrator since 10/30/24, administrator certificate number 6022084740, which expires 12/12/24. This was verfied by a records review of the personnel record and criminal record transfer request form. Upon conducting a tour of the interior of the physical plant LPAs observed for there to be a valid administrator certificate posted in the entryway. In athe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 18-AS-20241106142616

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: Facility staff are not ensuring that resident has access to a phone while in care.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation listed above. LPA was granted entry and met with Buisness Office Manager Ashlee Theus. The allegation was investigated and consisted of observation, interviews, and record review. Regarding the allegation “Facility staff are not ensuring that resident has access to a phone while in care”, it was alleged a telephone is not accessible to Resident One (R1) who is bedridden. LPA conducted an interview with Business Office Manager Ashlee Theus regarding residents’ accessibility to a telephone at the facility. Theus stated there is a telephone accessible to every resident in each villa at the facility. Residents who do not have a cellphone with an ambulatory status of bedridden can request to use the administrative staffs’ cellphone while on duty to make outgoing calls or receive calls. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2024 · control 18-AS-20231219181442

Allegation investigated: Residents fell while in care. Resident sustained pressure ulcers while in care. Resident sustained unexplained bruisinig while in care. Staff did not provide water to residents. Staff did not provided resident with their own hygiene supplies. Staff not meeting residents needs.

Licensing Program Analyst (LPA) Rayshaun Nickolas met with Executive Director Diana Molina-Ramirez and Business Office Manager Ashlee Theus in the Riverside/San Bernardino Regional Office to deliver findings on the above allegations. Department staff investigated the above allegations, and LPA Nickolas also conducted facility tours, file reviews, and additional interviews pertinent to this investigation. Allegation #1 “Residents fell while in care”. The allegation alleged that client #1 (C1), a month before this allegation, was made fell with no injuries. The allegation alleged that client #2 (C2) also fell, and their health has declined since their fall. Department staff interview with the reporting party (RP) revealed that they were advised of the fall by other facility staff members, but there is no evidence that the fall occurred on the date(s) advised. The RP also discusses other falls with another client (client #3 [C3]) that was not originally reported. Department staff interviethe state’s words, verbatim · CDSS document, Sep 13, 2023 · control 18-AS-20200820153416

Allegation investigated: Hazardous items accessible to residents.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Ashlee Theus and explained the purpose of the visit. The Executive Director Diana Molina Ramirez, later arrived at the faciliy. Department staff investigated the above allegation, and LPA Nickolas also conducted facility tours, file reviews, and additional interviews pertinent to this investigation. The allegation alleged that cleaning products are left out for residents to access. On August 7, 2023, LPA Nickolas conducted a facility tour with staff #1 (S1) and discovered a bottle of cleaning solution in an unsecured credenza located in Villa 2. LPA Nickolas questioned S1 about the cleaning solution. S1 stated they did not know why the solution was not placed in the secured cabinet. S1 questioned an unidentified member of the facility staff working in that building, and that staff stated that it was there when they arrived. Substantiatedthe state’s words, verbatim · CDSS document, Sep 6, 2023 · control 18-AS-20200820154620

Allegation investigated: Resident sustained multiple falls at the facility while in care.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Business Office Manager Ashlee Theus and explained the purpose of the visit. The Exective Director Diana Molina-Ramirez, later arrived at the facility.The investigation included facility tours, file reviews, and interviews with relevant parties. The allegation alleged that client #1 (C1) has had three (3) falls within a six (6) months span of time while residing at the facility. LPA Nickolas's interview with staff #1 (S1) revealed that they were familiar with C1 but unfamiliar with C1's three (3) falls within a six (6) months period. LPA Nickolas' interview with staff #2 (S2) revealed that they could not provide any information about C1's falls within six (6) months. S2 stated that C1 would rock back and forth while in bed. LPA Nickolas' interview with staff #3 (S3) revealed that S3 was an assigned caregiver to C1. S3 stated that C1 liked to dothe state’s words, verbatim · CDSS document, Sep 6, 2023 · control 18-AS-20220503163805

Allegation investigated: Licensee failed to supervise resident.

Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegation. LPA Nickolas met with Wellness Coordinator Monica Quinones and explained the purpose of the visit. The Executive Director, Diana Molina Ramirez, would arrive at the facility later. The investigation included file reviews, a tour of the facility, and interviews with relevant parties. The allegation alleged that on September 7, 2022, client #1 (C1) jumped out of the window and eloped from the facility. The allegation alleged that during a routine check at the facility, staff #1 (S1) was notified by another client that C1 jumped out of the window. LPA Nickolas’ interview with staff #2 (S2) and staff #3 (S3) revealed that they were not present when the incident occurred. LPA Nickolas’ interview with C1 revealed that C1 could not participate in the interview process. LPA Nickolas’ file reviews revealed that the facility had sufficient staff working the night ofthe state’s words, verbatim · CDSS document, Aug 28, 2023 · control 18-AS-20220908145705

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