Citrus Breeze Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Yodit Gebray, Caregiver and explained the purpose of the visit. At 3:30pm, administrator Yom Tekeste arrived and assisted LPA. The facility is licensed to care for age range 60 and over. Approved for (6) non ambulatory and has an approved hospice waiver for (2). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Staff are trained in the proper use of required PPEs. Operational Requirements: A fire clearance is in place. Fire Drill has not been conducted with staff yet as there are (0) residents in the facility. Facility has signal systems installed in exit points but are inoperable. Liability insurance is valid and expires on 01/06/2027. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, but (1) of the bedrooms is currently being used as a staff bedroom, (4) bathrooms, (2) living rooms with fireplace, office area, kitchen, dining area, attached garage, laundry area in the garage, backyard with shaded patio area. Currently, there is (1) resident in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and has a shaded area and sitting area. There is (1) fire extinguisher in the facility. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C***** Staffing: There are (2) staff including the Administrator who provide care and supervision to the resident. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, and associated to the facility. Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate expires on 06/23/2026. Resident Rights-Information: Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly. Incidental Medical Services: The facility uses Medication Administration Record (MAR) log to document medications given. Resident's medications are centrally stored in a locked cabinet in the office area. Resident Records-Incident Reports: (1) resident file was reviewed containing admission agreement, Physician's Report, Medical/Functional assessment, Needs and Services Plan, Personal rights and Medical Consent. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility conducts emergency drill on a quarterly basis. Last fire drill was conducted on 07/18/2025 Residents with SHN: Appraisals were observed in resident's files. There are zero (0) dementia, hospice or bedridden resident. No resident uses oxygen. Resident uses a half bed rail used only for assistance authorized by a physician Deficiencies cited and Technical assistance issued. Exit interview and a copy of this report was provided to the Administrator, Yom Tekeste.the state’s words, verbatim · CDSS document, May 11, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Daniel Konishi made an announced visit and met with Licensee/Administrator, Yom Tekeste conduct an announced Pre-Licensing evaluation. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. Approved for six (6) ambulatory, of which six (6) may be non-ambulatory residents. Structure: Facility is a single-story home located in a residential area consisting of four (4) bedrooms, three (3) residents’ bathrooms, kitchen, dining room, living room, family room, garage, and a backyard with seating and shade. Front entry and all exits have a wheelchair ramp. Operational Requirements: The facility did not have proof of liability insurance during today's visit and that they were instructed to obtain the liability insurance prior to accepting the first resident and will submit proof of that insurance to the department once it is obtained. Bedroom Clients: Bedrooms are equipped with a bed, nightstand, chair, lamp, dresser, trash bins, and overhead lighting. Bathrooms: Two (2) full bath equipped with working toilet, wash basins, bathtub/shower and two (1) full bath equipped with working toilet, wash basins, walk in shower. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in linen closets. Emergency Phone Numbers, Exit Plan: Emergency numbers and Exit plans are posted and readily available for review. One (1) fully charged fire extinguisher was observed. Facility has a land line telephone. Food Service: Facility has sufficient weekly supply of non-perishable foods. Dishes, cups, and flatware are stored in the kitchen cupboards, all equipment, inspected and in good repair. All equipment Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Emergency water supply was observed. Carbon Monoxide/Smoke Detectors were observed and tested. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in good condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Resident & Staff Files: Designated area for files will be in locked closet. Pools/Jacuzzi/Body of Water: No bodies of water were observed. Fire Clearance: Fire clearance was approved on 12/11/2024 for six (6) ambulatory, of which six (6) may be non-ambulatory residents. Component III: Component III was reviewed during inspection. Pre-Licensing is complete, and this facility has no deficiencies. Exit interview was conducted with the Licensee/Administrator, Yom Tekeste and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 25, 2025