Citrus Crest Care Home 1

Allegation investigated: Staff did not address resident’s fall risk Staff yell at resident

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Care staff Hyacinth Morris to deliver findings for the above complaint allegation. LPA spoke with Licensee via phone to inform of visit. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded Staff did not address resident’s fall risk Records reviewed indicated that there have been no incidents or falls for resident R1 in the last three months prior to initial visit on 04/23/2026. Staff assist R1 with their care and needs in order to help prevent falls. Observations indicated that residents in care are monitored for fall risk and staff are quick to assist when residents need or request assistance. Interviews conducted indicated facility and staff have addressed resident’s fall risk and are monitoring closely along with hospice care. R1 also has physical therapy that is seeing R1 weekly for additional support. Staff encourage R1 to use walker or wheelchair when moving about the facility but sometime R1 does not which causes a fall. Therefore, the allegation staff did not address resident’s fall risk is unfounded. Staff yell at resident Interviews conducted with residents indicated that residents are happy with the care that is being received and staff are helpful. Interviews with staff indicated that staff sometimes have to speak in a louder voice due to resident hearing loss but they do not yell at residents. Observations indicated that staff are speaking respectfully to residents in care and only will speak in a louder voice if the resident did not hear the staff the first time. Therefore, the allegation staff yell at resident is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260413111022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Care Staff Hyacinth Morris to conduct an annual inspection utilizing the inspection tool. LPA spoke with Assistant Administrator Mariam via phone. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas, staff quarters and perimeter of care home. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 112.8 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files, two (2) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Mar 17, 2026

Allegation investigated: Illegal eviction.

On 08/13/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility and met with Staff, Pauline Myres to deliver findings into the allegation listed above. LPA explained the pupose of today's visit. Administrator, Mariam Soumahoro was not avaiable so administrator gave permission to staff via phone, Pauline Myres to conduct today's visit and sign the report. Allegation- Illegal eviction. Substantiated The department reviewed records, interviewed witnesses, and administrator to investigate this allegation. Record review indicated that facility issued 30 days Eviction Notice to resident, R1 on 06/04/25 with the reason indicating “needs high level of care”. It was noted that there was no documentation from facility to indicate why facility was not able to meet resident’s care needs with current care plan. Additionally, facility did not send Eviction Letter from 06/04/25 issued to R1 for Departmental review and approval as required. Interviews and record review reflected that R1’s family and/or responsible party moved R1 from the facility on 06/05/25. Based on gathered information, this allegation was found to be Substantiated. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC9099-D page.Exit interview was conducted . A copy of this report and appeal rights were provided. Substantiated ***Report continued from 9099-A.... Allegation- Staff are not feeding resident. Unsubstantiated The department reviewed records, facility’s observations and interviewed witnesses, three staff members and three residents to investigate this allegation. Staff interviews indicated that facility has adequate food supplies and resident’s dietary needs were met per resident’s care plans and there were no issues identified. Resident interviews indicated that facility was providing meal services to them per their dietary needs and preferences and there were no complaints. Furthermore, record review indicated that resident, R1 moved into the facility in August 2024 and per LIC602, R1 weight was 130 lbs. R1’s weight was noted to be 133 lbs during a medical visit on 06/05/25. Medical records indicated there were no issues regarding R1s weight loss or dietary needs. During department visits, it was observed that facility has adequate food supplies per Regulations. Based on gathered information, this allegation was found to be Unsubstantiated. Due to the observations and interviews, LPA finds this allegation to be UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 59-AS-20250605143636

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224 · Plan of correction due date: Aug 27, 2025

87224-(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)....(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted ...this requirement is not met as evidence by; Record review indicated that facility issued 30 day eviction letter to resident, R1 on 06/04/25 but did not conduct reappraisal and did not send this for departmental review for approval before issuing which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Licensee/Administrator shall send a letter of understanding of this regulation and to ensure to follow this regulation for all residents per operational needs. All POC requirements are due by 08/27/25.

Type of visit: Case Management - Incident

On 05/28/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit regarding an incident report and death report that the department received on 05/26/2025 . LPA met with Staff Mariam Soumahoro and explained the purpose of the visit. The purpose of the visit is to gather more information regarding an incident and death report Community Care Licensing (CCL) received on 05/26/2025. LPA obtained a copy of R1's LIC602 and ID page. At this time, no deficiencies are cited. Exit interview conducted and a copy of the report and LIC809G was left at the facility.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

On 02/10/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the inspection tool. LPA met with staff Hyacinth Morris. Staff and LPA conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, kitchen, common areas and the backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured at 106.7 degrees Fahrenheit in the kitchen sink which is within the required ranged of 105 to 120 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed the fire extinguisher located in kitchen last inspected on 08/27/24. LPA observed required Licensing posters posted throughout the facility. LPA reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed two (2) staff files. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed. LPA requested for Administrator to email LPA a copy of the LIC308 and Liability Insurance by 02/14/2025. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Feb 10, 2025

Type of visit: Required - 1 Year

On 02/15/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff, Ruth Tumukunde, and explained the purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility. Administrator, Muamoudou Soumahoro later arrived at the facility. At 9:19 LPA and staff toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage, laundry room, and backyard. While on the tour LPA observed bathroom cleaner, windex and Tide Spray in an unlocked bathroom cabinet. Caregiver immediately removed items and place them in a locked cabinet. LPA conducted a file review of two (2) personnel and five (5) residents records. LPA compared medications to those being given for two (2) residents and found no discrepancies. LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 15, 2024