Citrus Hills Assisted Living

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Allegation investigated: Staff does not ensure resident's catheter needs are being met resulting in resident developing an infection

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the facility and interviewed staff and resident. Regarding the allegation that staff does not ensure resident's catheter needs are being met resulting in resident developing an infection, the investigation revealed the following: Resident 1 (R1) does not have a urinary catheter however the resident has a port for dialysis. LPA reviewed hospitalization records from 07/19/2026 and 07/22/2026 and there is no documentation of resident being seen for any urinary or port infection. Resident denies an infection. Based on interviews conducted and record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfounded Four out of four staff state the resident is checked throughout the day. Caregiver checklist show staff are checking on the resident. Three out of three staff state the resident calls when incontinence care is needed. The staff state the response time is under 10 minutes. The resident denies an issue with response times stating the staff come as often as the resident needs. LPA reviewed caregiver checklist which shows incontinence care is being provided. Three out of three residents state satisfaction with caregiving at the facility. Staff and administrator indicate ongoing issues with R1's roommates. Three out of three staff and administrator indicate R1 is the instigator of issues and the facility has swapped roommates for R1 four times. LPA unable to interview R2 as the resident was sent out to the hospital. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, this allegation is deemed UNSUBSTANTIATED. Exit interview conducted and a copy of this report will be provided.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 22-AS-20260726175917

Allegation investigated: Facility did not provide supervision to meet the resident's needs

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 07/05/2024. ** Continued on 9099-C page Unsubstantiated Facility did not provide supervision to meet the resident's needs Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20240705141218

Allegation investigated: Facility is mishandling resident's medication Facility is failing to report incidents Facility beds are not equipped with clean linens Facility is not providing resident's responsible party with requested documents

On 07/28/2026, Licensing Program Analyst (LPA) Mikkelson contacted the licensee via email to deliver final findings regarding a complaint that was received on 12/15/2023. ** Continued on 9099-C page Unsubstantiated Facility is mishandling resident's medication Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility is failing to report incidents Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility beds are not equipped with clean linens Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility is not providing resident's responsible party with requested documents Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20231215152116

Allegation investigated: Facility staff are not allowing resident to receive telephone calls

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on April 2, 2026. LPA was greeted and granted entry into the facility and met with Wellness Coordinator (WC) Mansi Modi. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility staff are not allowing resident to receive telephone calls. Regarding the allegation the following was revealed: During the interviews with individuals five of six individuals interviewed denied the allegation. During the investigation LPA reviewed the Citrus Hills Assisted Living Admission Agreement dated February 10, 2025, for Resident 1 (R1). Per Admission Agreement, under Telephone Services it states the community shall provide any deaf, hearing impaired, or otherwise impaired resident with equipment and services. During the interviews with residents, R1 reported that staff helped her talk to her brother. Per R1, she used the staff's cellphone. R2 and R3 reported that they are allowed to make and receive calls. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews with staff, Staff 1 (S1) reported that when they called, R1 was sleeping. S1 stated that the following day R1 used the work cellphone to talk to her brother. S2 reported that staff always allow the residents to receive telephone calls. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 22-AS-20260402153318

Allegation investigated: Resident's needs were not met Resident developed sores due to lack of care and supervision Staff were not responsive to resident's authorized representative Residents were not accorded a safe environment Staff did not safeguard resident's personal belongings Staff did not ensure laundry washer and dryer were in good repair

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on March 19, 2026. LPA was greeted and granted entry into the facility and met with Wellness Coordinator (WC) Mansi Modi. LPA explained the reason for the visit. This Department has investigated the complaint alleging that resident's needs were not met. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Physician Report (LIC602A) dated October 17, 2025, for Resident 1 (R1). Per Physician report, R1 is able to communicate needs, able to feed self and is not able to administer own oxygen. LPA reviewed the Mission Hospice sign in log dated December 17, 2025, through March 11, 2026, for R1. Per sign in log, on average the resident was given a bath every other day. LPA reviewed the Service Plan Report dated March 19, 2026, for R1. Per Service Plan Report, under Oxygen interventions it states reminders to keep nasal cannula in place. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews with resident, R2 reported that staff help her with her showers and with washing her clothes. R3 reported that staff are meeting her needs. During the interviews with staff, Staff 1 (S1) through S3 reported that staff are meeting the residents' needs and/or reported that staff assists the residents with their Activities of Daily Living (ADLs) such as meals and oxygen. Regarding the allegation that resident developed sores due to lack of care and supervision, the following was revealed: During the investigation LPA reviewed the Hospice Plan of Care dated February 10, 2026, for R1. Per Hospice Plan of Care, it states primary diagnosis Non rheumatic Tricuspid (Valve) Insufficiency. Per Hospice medication list, on February 5, 2026, R1 was prescribed Betadine Swabsticks 10 % for Wound Care. Per Hospice medication list, on February 19, 2026, the Wound Care medication was discontinued. During the interviews with residents, R2 and R3 reported that they have not develop sores due to lack of care and supervision. During the interviews with staff, S1-S3 reported being unaware and/or stated that they never noticed sores on R1. During the interviews the Executive Director (ED) reported that R1 did not develop sores due to lack of care and supervision. Regarding the allegation that staff were not responsive to resident's authorized representative, the following was revealed: During the investigation LPA reviewed the Citrus Hills Assisted Living Admission Agreement dated February 10, 2025, for R1. Per Admission Agreement under Family Visits, it states the community's policy...intends to encourage family involvement with residents and to provide ample opportunity for family participation. During the interviews with residents, R2 reported that management communicates with her sister and stated that she has no issues. During the interviews with staff, S1-S3 reported not being aware. During the interviews the ED reported that management is responsive and communicates with the resident's authorized representative. Regarding the allegation that residents were not accorded a safe environment, the following was revealed: During the interviews with residents, R2 reported that she feels safe here. Per R3, the residents are being provided a safe environment. During the interviews with staff, S1-S3 reported that the residents are accorded a safe environment and/or reported that staff are always doing rounds throughout their shift. During the interviews the ED stated that management monitors the hallway entrance/exit cameras. ED reported that they do not have an issue with homeless coming into the facility. CONTINUED ON LIC9099-C... Regarding the allegation that staff did not safeguard resident's personal belongings, the following was revealed: During the investigation LPA reviewed the Service Plan Report for R1. Per Service Plan Report, under laundry tasks it states resident requires assistance with laundry once a week on Fridays in the evening. During the interviews with residents, R2 and R3 reported that staff safeguard their personal belongings and/or stated that staff do an outstanding job. During the interviews with staff, S1 reported that when she washed for R1 that she would place his clean socks and bedding in his closet. S2 and S3 stated that after washing the residents' clothes that staff return the residents' personal belongings back to the resident's closet. Per ED, staff never lose the residents' personal belongings. Regarding the allegation that staff did not ensure laundry washer and dryer were in good repair, the following was revealed. During the initial visit on March 27, 2026, and subsequent visit on June 5, 2026, LPA tour the facility and observed that the washers and dryers were working properly. During the interviews with residents, R2 reported that the dryer and washer are in good repair. R3 stated that his clothes always get washed. During the interviews with staff, S1-S3 reported that the washer and dryer were replaced recently and stated that they can use the backup washer and dryer. During the interviews the ED reported that the washer and dryer have never been in disrepair and stated that there are three sets. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 22-AS-20260319124734

Allegation investigated: Staff did not answer resident's call button in a timely manner. Staff did not assist resident with incontinence needs. Staff did not provide resident with clean linens. Staff did not allow resident to present grievances/recommendations to facility management.

On 06/02/2026, Licensing Program Analyst (LPA) contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 11/28/2023. **Report continued on 9099-C page Unsubstantiated Staff did not answer resident's call button in a timely manner. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not assist resident with incontinence needs. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not provide resident with clean linens. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not allow resident to present grievances/recommendations to facility management. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. A finding that a complaint allegation is unsubstantiated means 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 22-AS-20231128150704

Allegation investigated: Staff did not answer phone calls at the facility. Resident's personal information was stolen while in care. Staff did not inform family of a resident's fall. Staff did not seek resident timely medical attention.

On 06/02/2026, Licensing Program Analyst (LPA) contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 04/17/2024. ***Report continued on 9099-C page Unsubstantiated Staff did not answer phone calls at the facility. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Resident's personal information was stolen while in care. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated.. Staff did not inform family of a resident's fall. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not seek resident timely medical attention. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated.. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 22-AS-20240417125905

Allegation investigated: Staff did not provide a safe environment for a resident in care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Charles Marinko. LPA explained the reason for the visit. This agency has investigated the complaint alleging that staff did not provide a safe environment for a resident in care. Regarding the allegation, the following was revealed: During the interviews with individuals six of eight individuals interviewed denied the allegation. During the interviews with residents, Resident 1 (R1) reported that at the beginning of the month R2 was drunk and wanted to beat him up. Per R2, one day R1 was telling him what to do with his business. R2 reported that staff are providing a safe environment for residents in care. R3 and R4 reported that they are not aware about the incident and/or stated not being familiar with R1 and R2. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews with staff, Staff 1 (S1) reported that they heard the residents yelling at each other and stated that staff separated the residents. S1 stated that staff are providing a safe environment for the residents. During the interviews the ED reported that he has never witness R2 being aggressive. Per ED, R1 was offered a new room; however, R1 did not want to move. ED stated that staff provide a safe environment for residents in care. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 28, 2026 · control 22-AS-20260521094559

Allegation investigated: Staff does not allow resident to have access to resident's pull cord.

On 05/15/2026, Licensing Program Analyst (LPA) contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 11/21/2023. Staff does not allow resident to have access to resident’s pull cord. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. A finding that a complaint allegation is unsubstantiated means 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. Administrator was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20231121100820

Allegation investigated: Facility failed to take proper COVID precautions Facility did not notify family of COVID outbreak Facility staff failed to meet resident's needs Facility staff did not seek appropriate medical care Facility staff did not provide proper care and supervision to resident

On 05/15/2026, Licensing Program Analyst (LPA) contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 02/01/2021. **Continued on 9099- C page Unsubstantiated Facility failed to take proper COVID precautions Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility did not notify family of COVID outbreak Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff failed to meet resident's needs Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff did not seek appropriate medical care Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility staff did not provide proper care and supervision to resident Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20210201090446

Allegation investigated: Staff touched resident inappropriately

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Executive Director (ED) Charles Marinko. During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained documentation such as Admission Agreement, Physician Report (LIC602), Preplacement Appraisal Information, Citrus Hills Assisted Living Service Plan Report, Resident Roster, and Staff Schedule. The Department has investigated the complaint alleging that staff touched resident inappropriately. Resident 1 (R1) was admitted to the facility on April 26, 2024. R1’s Physician Report dated April 17, 2024, lists R1 as having a diagnosis of Hypertension. During the interviews with individuals seven of nine interviewed denied the allegation. During the investigation LPA reviewed documents including the Physician Report for R1. Per Physician Report, R1 is ambulatory and is able to bathe self. CONTINUED ON LIC9099-C... Unsubstantiated LPA also reviewed the Citrus Hills Assisted Living Service Plan Report dated January 4, 2026, for R1. Per Service Plan Report, R1 requires assistance for bathing/showering on Wednesday evening and Saturday morning. During the interviews with residents, R1 reported that during a shower that staff touched her in her private area. R1 stated that she does not recall the date of the incident and/or the staff's name. R2-R4 reported that they have never been touched inappropriately by staff and/or stated that staff have never touched them inappropriately when assisting them with taking a shower. During the interviews with staff, three of three staff interviewed reported that staff have never inappropriately touched the residents and/or stated that staff respect the residents’ personal rights. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 22-AS-20260122151046

Allegation investigated: Facility increased resident rent in excess of the allowed SSI/SSP amount.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a complaint investigation into the above mentioned allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Charles Marinko and discussed the purpose of the visit. Regarding facility allegation of Facility increased resident rent in excess of the allowed SSI/SSP amount revealed the following: It was alleged that staff notified Witness #1 (W1) of an excessive rent increase starting August 1, 2022. LPA observed Resident #1(R1) admission agreement and was admitted to the facility on November 6, 2020. LPA observed the agreement was signed by R1, R1s responsible party and facility staff. LPA observed the admission agreement stating that the facility has the right to change the amount of the fees at any time with a 60 day written notice. LPA observed that the rent for R1 was to be $1200 at the time the agreement was signed. Continue on 9099C Unfounded LPA reviewed a rate increase letter dated May 22, 2022, stating that on August 1, 2022, R1s rate will increase to $3000 a month with an extra service charge of $900. This letter was signed by facility staff and sent to R1s responsible party. LPA observed rental statements for R1 from their responsible party from April 2022- October 2023 showing that the rent stayed at $1200 and that the rate increase did not go into effect. Interviews with 2 of 7 staff revealed that R1 did not have a rate increase until November of 2023. 2 of 7 staff informed LPA that the rent increase letter found in R1s file was never put into effect and they never paid that amount during their time at the facility. 2 of 7 staff informed LPA that R1 moved out of the facility in 2025. 5 of 7 staff informed LPA they were care staff and would not know about rent. LPA was unable to interview R1 due to not residing at the facility any longer. Based on the information gathered and the interviews conducted, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was left at the facility. LPA interviewed staff and 6 of 7 staff have informed LPA that the call system has always been operational. 6 of 7 staff revealed that if a call light is malfunctioning, the maintenance director fixes it right away and does not delay fixing the issue. 6 of 7 staff informed LPA that the response time is expected to be 10 minutes or less. 6 of 7 staff informed LPA that all calls are responded to no matter what. 6 of 7 staff informed LPA that the call lights give a notification when the batteries are low. 1 of 7 staff work in the business office and do not attend to call light signals. LPA interviewed residents and 7 of 7 residents informed LPA that their lights were operational. 7 of 7 residents informed LPA that their chords have always been operational. 6 of 7 residents informed LPA that staff always respond to the light and assist them. 1 of 7 residents informed LPA that the staff do not always respond to the signal system. Regarding the facility allegation of Facility is not maintained in conformity with the regulations adopted by the State Fire Marshal revealed the following: It was alleged that the electrical facility plugs were not operational or mounted to the wall correctly. LPA observed all plugs to be on the facility wall to be placed correctly and no wires were exposed. LPA did not observe any reports stating the plugs were not operational in 2022. Regarding the facility allegation of Facility staffing is inadequate to meet resident's needs revealed the following: It was alleged that due to a high turnover of staff, resident needs are not being met. LPA was unable to review staff schedules for the year of 2022. LPA observed a current staff schedule that reflected 5 care staff are on the morning shift, 5 care staff are on the evening shift and 2 care staff are on the over night shift. LPA observed an in service that was conducted on October 15, 2025, on the topic of call light responses and resident communications. Interviews with 7 of 7 residents revealed to LPA that the staff assist them and their needs are taken care of. 5 of 7 residents informed LPA that they are more independent and do not need as much assistance. 2 of 7 residents informed LPA that they get assistance whenever needed even for things that do not pertain to their care. Based on information gathered and interviews conducted, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 22-AS-20220523154103

Allegation investigated: Staff do not ensure that resident hygiene needs are being met

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Business Office Manager (BOM) Lynn Vuong. LPA explained the reason for the visit. This agency has investigated the complaint alleging that staff do not ensure that resident hygiene needs are being met. Regarding the allegation, the following was revealed: During the course of the interviews seven of seven individuals interviewed denied the allegation. During the course of the investigation LPA reviewed documents including the Physician Report (LIC602) dated July 17, 2025, for Resident 1 (R1). Per Physician, Report R1 is not able to bathe self. LPA reviewed documents including the Citrus Hills Assisted Living shower schedule. Per shower schedule R1 is schedule to shower on Sunday and Thursday mornings. During the course of the interviews with residents, R1 reported that staff are meeting his hygiene needs and stated that he showers two times per week. CONTINUED ON LIC9099-C... Unsubstantiated Per R2-R5 staff are meeting their hygiene needs. During the course of the interviews with staff, Staff 1 (S1) reported that staff are meeting the residents' hygiene needs and reported that the residents shower two times per week. S2 stated that staff are meeting the residents' hygiene needs and reported that staff will shower the residents as needed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with Wellness Coordinator Modi, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 22-AS-20251016114707

Type of visit: Required - 1 Year

On October 16, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Charles Marinko was present and assisted with today's inspection. LPA observed that Charles Marinko has a valid Administrator certificate which expires on December 16, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for ninety five non-ambulatory residents, of which twelve may be bedridden, and has a hospice waiver for twenty. The facility is a two story building that consist of staff offices, a medication room, a maintenance room, an activity room, two storage room, salons, two laundry room, common showers, resident bedrooms and bathrooms located on the first and second floors. LPA accompanied by the ED, conducted a tour of the interior portions of the facility. On today's visit, there are eighty eight resident in care. LPA observed residents eating lunch in the dining rooms which consisted of food of their choice. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected random resident bedrooms on the first and second floor of the facility. Resident bedrooms were observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a storage room. LPA tested the call system in resident bedrooms and they tested operational. LPA inspected the resident bathrooms in each bedroom inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 109.5 and 114.4 degrees Fahrenheit. CONTINUED ON 809-C LPA inspected the facility kitchen area and observed it be clean. LPA observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPA observed multiple fire extinguishers to be mounted in the wall on the first and second floor of the facility. All fire extinguishers were observed to be charged and serviced as of November 6, 2024. LPA observed that the facility had their most recent Fire Inspection conducted on October 14, 2025. LPA observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPA observed the facility conducted their last emergency disaster drill on October 14, 2025. LPA observed the centrally stored medication to be kept in locked medicine carts located in the medication room. LPA observed First Aid Kits in the medication room and they had all the required components. LPA observed all the facility's chemicals and toxins to be stored in a locked maintenance room. LPA observed other common areas such as the dining room, staff offices, and activity room to be clear of any hazards. LPA, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use. There are no bodies of water on the premises. LPA reviewed the eight resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents' medication and medication administration records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Charles Marinko and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff handled resident in a rough manner Staff did not respond to resident’s call in a timely manner Staff refused to shower resident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on March 28, 2025. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Charles Marinko. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff handled resident in a rough manner. Regarding the allegation the following was revealed: During the course of the interviews seven of nine individuals interviewed denied the allegation. During the course of the interviews with residents, Resident 1 (R1) reported that staff dragged him into the bathroom using his wheelchair. Per R2, staff have never grabbed her in a rough manner and stated that she has not heard residents complained about staff handling them in a rough manner. R3 reported that staff have never handled him in a rough manner and stated that staff treat him nice. Per R4, staff have never handled her in a rough manner and stated that staff are very good people. During the course of the interviews with staff, Staff 1 (S1) reported that she push the wheelchair and wheeled R1 into the bathroom and stated that nothing was forceful. CONTINUED ON LIC9099-C... Unsubstantiated Per S2, she did not witness the caregiver handling the resident in a rough manner. During the interviews with witnesses, Witness 1 (W1) stated that it is hard to know if the incident happened since she was not there during incident. Regarding the allegation that staff did not respond to resident’s call in a timely manner, the following was revealed: During the initial visit on April 3, 2025, LPA pull the call light for R1 and R3. Staff responded to the call light between one minute and 21 seconds to two minutes and 57 seconds. During the course of the investigation LPA reviewed documents including the Citrus Hills Assisted Living call light dated March 27, 2025, for R1. Per call light log R1 used the call light two times and was assisted between four minutes and 26 seconds to 30 minutes and 49 seconds. During the course of the interviews with residents, R3 reported that staff respond to the resident's call within 10-20 minutes. Per R4, she does not use the call bell and stated that staff respond within 25 minutes because staff are busy. R5 reported that staff respond to the residents’ calls in a timely manner. During the course of the interviews with staff, S1 reported that the resident's call bell was answer within five minutes. S2 stated that the resident waited approximately 30 minutes. Regarding the allegation that staff refused to shower resident, the following was revealed: During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated April 3, 2025, for R1. Per UIIR on March 27, 2025, R1 refused to shower. LPA reviewed documents including the Citrus Hills Assisted Living shower schedule. Per shower schedule R1 is schedule for a shower on Mondays and Fridays. During the course of the interviews with residents, R2-R4 reported that staff have never refuse to shower them and/or stated that staff always help when taking a shower. During the course of the interviews with staff, S1 reported that resident refused to shower. Per S2, resident refused to shower. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility. During the course of the interviews with witnesses, Witness 1 (W1) reported that her father is pretty self sufficient. Per W1, the facility did notified her of the incident. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA Ramirez conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20250328123833

Allegation investigated: Facility did not meet the resident's needs Facility did not meet the resident's incontinence needs resulting in urine odor Staff did not maintain the facility in clean and sanitary conditions

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 4, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Charles Marinko. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not meet the resident's needs. Regarding the allegation the following was revealed: During the course of the investigation LPA reviewed documents including the Citrus Hills Assisted Living Service Plan Report dated April 11, 2024, for Resident 1 (R1). Per Service Plan Report, R1 was provided with three meals daily and snacks. Per Service Plan, R1 was assisted to be transferred from bed to their wheelchair for meals. Per Service Plan, R1 was assisted with bathing/showering on Tuesday and Thursday. Per Service Plan, resident’s toileting needs will be met or will receive assistance as needed. During the course of the interviews with residents, R3 reported that the facility staff meet her needs. CONTINUED ON LIC9099-C... Unsubstantiated Per R5, the facility meets his needs and reported that he gets fed and always gets clean bedsheets. During the course of the interviews with staff, Staff 1 (S1) reported that the facility was meeting the resident’s needs. Per S1, staff change the bedsheets as needed. Regarding the allegation that facility did not meet the resident's incontinence needs resulting in urine odor, the following was revealed: During the investigation LPA reviewed the Citrus Hills Assisted Living Routine Changes for R1. Per Routine Changes, R1 should be changed every two hours. During the course of the interviews with residents, R3 reported that she has not heard that staff do not meet the resident’s incontinence care. Per R3, she has not smell a strong odor of urine. R5 reported that the facility does not smell like urine. During the course of the interviews with staff, S1 reported that staff check on the residents’ diapers every two hours and stated that every shift does rounds at the beginning of their shift. During the interviews the AD reported that staff always check on the residents’ at the beginning of their shift and stated that staff check on the residents’ diapers every two hours. Per AD, she has never smell a strong urine odor. Regarding the allegation that staff did not maintain the facility in clean and sanitary conditions, the following was revealed: During the initial visit on April 11, 2024, and subsequent visits on September 24, 2025, and October 1, 2025, LPA tour the facility and observed staff cleaning the residents bedrooms and bathrooms, common areas and washing the residents bedding. During the course of the interviews with residents, R3 reported that the facility is clean and sanitary and stated that staff clean right away. Per R5, facility is kept clean and sanitary and reported that his bedroom gets clean every other day. During the course of the interviews with staff, S1 reported that all staff contribute to keep the facility clean. Per S1, lately R1’s bedroom is clean daily and stated that the trash is taken out daily. During the interviews the AD reported that R1’s trash gets taken out each shift. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20240404151704

Allegation investigated: Facility staff failed to ensure resident receive unopened correspondence in a prompt manner. Facility staff required resident to open their packages in front of staff. Facility staff verbally harassed resident.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on July 12, 2023. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Charles Marinko. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility staff failed to ensure resident receive unopened correspondence in a prompt manner. Regarding the allegation the following was revealed: During the course of the interviews two of eight individuals interviewed confirmed the allegation. During the course of the interviews with residents, Resident 1 (R1) reported that staff deliver his mail unopened. Per R2, staff bring her mail to her bedroom and stated that her mail is never open. R3 reported that the mail man provides his mail and stated that his mail is always sealed. Per R4, staff members made him open his package in front of them. During the course of the interviews with staff, Staff 1 (S1) reported that staff never open the residents’ mail. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews the AD reported that the receptionist delivers the residents mail and packages during lunch and/or after 3:00 p.m. Per AD, the residents always received their mail unopened. Regarding the allegation that facility staff required resident to open their packages in front of staff, the following was revealed: During the course of the interviews two of eight individuals interviewed confirmed the allegation. During the course of the interviews with residents, R1 reported that he does not have to open his packages in front of staff. Per R2, she does not have to open her packages in front of staff. R3 reported that his packages are always unopened. Per R4, staff members made him open his package in front of them. During the course of the interviews with staff, S1 reported that staff never require the residents to open their packages in front of them. During the interviews the AD reported that the residents have the right to refuse to open their packages. Per AD, if a resident receives a package that sounds like medication and the facility manages the resident's medication, staff will ask the resident if they could open the package so that the medication can be put in the Medication Room. Regarding the allegation that facility staff verbally harassed resident, the following was revealed: During the course of the interviews with residents, R1 reported that he has never been harassed by staff and stated that staff are good people. Per R2, staff are respectful and do not harass her. R3 reported that staff do not verbally harass him. Per R4, staff are pushy and demanding. During the course of the interviews with staff, S1 reported that staff do not verbally harass the residents in care. Per S1, staff are respectful and are good people. During the interviews the AD reported that staff do not verbally harass the residents. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED Marinko, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20230712154640

Allegation investigated: Licensee used full bed rails for non-hospice resident. Staff did not ensure resident was provided with adequate bed linens.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by facility front desk staff after introducing himself and stating the purpose of the visit. An initial complaint investigation visit took place on November 20, 2024. LPA accompanied by the facility's Health and Wellness Director conducted a tour of the facility's two levels and reviewed a total of 10 units throughout the physical plant. One staff and three resident interviews were conducted. Records for five residents were requested and reviewed in addition to the facility's census, staff roster and facility shower schedule. During the present visit, LPA reviewed the current facility census. The physical plant was toured again and an additional five resident interviews were conducted. Five resident records requested and reviewed. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM LIC9099-A Regarding the allegation that Staff did not assist residents with mobility needs in a timely manner, the following has been concluded: Based on eight interviews conducted with facility residents along with tours of the physical plant, all residents with limited mobility met or observed were fully able to access the facility's call system from their bed. A majority of residents interviewed either stated no concerns with facility staff response time or stated that they were satisfied with response times. Regarding the allegation that Staff did not ensure resident’s showering needs were met, the following has been concluded: During a total of eight resident interviews conducted, a majority of residents stated that they received adequate assistance for their personal toileting care and expressed no complaints with the frequency of the showers provided by facility staff. As a result, both allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of the report provided. CONTINUED FROM FORM LIC9099 Regarding the allegation that Licensee used full bed rails for non-hospice resident, the following has been concluded: During the initial complaint investigation visit conducted on November 20, 2024, licensing staff observed resident R1 was placed in a hospital bed equipped with half-rails that were positioned lower than the head of the bed. Once the upper part of the bed frame became elevated, it was observed that the half-rails functioned the way full-length rails would. Based on interviews conducted and files reviewed, R1 was confirmed to not be received hospice care at the time of the visit. Regarding the allegation that Staff did not ensure resident was provided with adequate bed linens, the following has been concluded: Based on observation made during the initial complaint investigation visit, R1 had mobility issues related to a surgical intervention and was placed in a hospital bed. During the visit, linen were observed to be crumpled up underneath the resident, leaving the resident to lay on a bare mattress. As a result of both observations, the allegations are found to be Substantiated, meaning that the preponderance of evidence has been met. Deficiencies cited on an attached form LIC9099-D. An exit interview was conducted with facility staff and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 22-AS-20241114102450

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Feb 12, 2025

Per CCR 87606(a)(5)(B) on Postural Supports: "Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails." This requirement is not met as evidenced by: Based on observation and records reviewed, resident R1 was placed in a bed equipped with half rails functioning as full rails despite not receiving hospice care at the time. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: During the follow-up investigation, it was confirmed that R1 was no longer a facility resident. Full rails orders for current residents were reviewed and confirmed to be valid. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Feb 12, 2025

Per CCR Personal Accomodations and Services: "(...) the licensee shall assure provision of: Clean linen(..) The quantity shall be sufficient (...) to ensure that clean linen is in use by residents at all times." This requirement is not met as evidenced by: Based on observation and records reviewed, resident R1 was positioned on a bare mattress during the initial investigation visit. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: During the follow-up investigation, all rooms reviewed were adequately equipped with linen. Deficiency cleared.

Allegation investigated: Staff left resident in a soiled diaper for a long period of time. Staff did not replace resident's call button. Staff did not serve resident meals. Facility staff did not give the resident's medication as prescribed.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on November 01, 2024. LPA was greeted and granted entry into the facility and met with Receptionist Cindy Mora. LPA explained the reason for the visit. Clinical Director (CD) Angelica Perez Penate arrived shortly after. This Department has investigated the complaint alleging staff left resident in a soiled diaper for a long period of time. Regarding the allegation the following was revealed: During the course of the investigation LPA reviewed documents including the Citrus Hills Assisted Living Service Plan dated October 08, 2024 for Resident 1 (R1). Per Service Plan under Toileting for R1 it states incontinent of bladder requires assist from staff and incontinent of bowel requires assist from staff. Per Service Plan care staff to provide brief changes every two hours and as needed due to incontinence of bowel and bladder. During the course of the interviews with Residents, R1 reported that staff do not always change their diaper as needed and stated that sometimes they have to wait over one hour before staff can change their diaper. CONTINUED ON LIC9099-C... Unsubstantiated Per R2 staff change his diaper as needed and reported that he has never been left in a soiled diaper. During the course of the interviews with staff, Staff 1 (S1) reported that staff usually do rounds every hour and stated that no other residents have complained about being left in a soiled diaper for a long period of time. Per S2 she changes R1’s diaper as needed and stated that she checks on R1 at least every two hours. Regarding the allegation that staff did not replace resident’s call button, the following was revealed: During the initial visit on November 07, 2024, and subsequent visit on January 29, 2025, LPA observed that R1’s call button was replaced. During the course of the interviews with Residents, R1 reported that their call button was broken the whole night of October 31, 2024, and stated that the call button was broken until the evening the next day. Per R2 his call button works good and stated that it gets answered within 10-20 minutes. Per R3 the call button works properly. During the course of the interviews with staff, S1 reported that the facility has extra call buttons and stated that it can replaced the same day. Regarding the allegation that staff did not serve resident meals, the following was revealed: During the investigation LPA reviewed documents including the Citrus Hills Assisted Living Service Plan dated October 08, 2024 for R1. Per Service Plan under Nutrition/Eating it states Resident will be offered choices in menu, with escorts and meal assistance as requested or needed. Per Service Plan it states provide meals three times daily, meal trays per resident request and verbal reminders for meals. During the course of the interviews with Residents, R2 reported that he gets three meals per day. Per R4 staff bring her three meals to her bedroom per day and stated that she always gets her breakfast, lunch and dinner. During the course of the interviews with staff, S2 reported that when a resident is sick, the kitchen staff bring the meals to the residents' bedroom. Regarding the allegation that facility staff did not give the resident's medication as prescribed, the following was revealed: LPA reviewed documents including the Physician Report (LIC602A) dated May 10, 2023, for R1. Per Physician Report R1 is not able to administer own prescription medications. During the investigation LPA reviewed documents including the Medication Administration Record (MAR) dated October 01, 2024, to November 07, 2024, and MAR dated January 01, 2025, to January 31, 2025. Per MAR dated October 01, 2024, to November 07, 2024, R1 was given their medication as prescribed except on October 24 and 25. CONTINUED ON LIC9099-C... Per MAR on October 24 and 25 the medications Mirtazapine Oral Tablet 15 MG and Quetiapine Fumarate Oral Tablet 200 MG were not administered. Per MAR on October 24 and 25 the chart code was entered as 7 which stands for other/see Nurse note. Per Nurse note on October 24 and 25 it states that the medication needs to be ordered. Per MAR dated January 01, 2025, to January 31, 2025, R1 was given their medications as prescribed. During the course of the interviews with Residents, R2 reported that staff administer his medications and reported that he gets his medications timely after every meal. During the course of the interviews with staff, S1 reported that residents get their medications as prescribed and stated that R1 is getting their medications as prescribed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 22-AS-20241101164055

Allegation investigated: Staff inappropriately had resident sign documents without authorized representative knowledge. Licensee has changed residents' health insurance for financial gain.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on October 28, 2024. LPA was greeted and granted entry into the facility and met with Clinical Director (CD) Angelica Perez Penate. LPA explained the reason for the visit. This Department has investigated the complaint alleging staff inappropriately had resident sign documents without authorized representative knowledge. Regarding the allegation the following was revealed: During the course of the interviews with residents, Resident 1 (R1) reported that he signed his health insurance documents with his consent. Per R1 he switched to a better insurance. Per R3 he signs his own documents and reported that he has not changed his health insurance. During the course of the interviews with staff, Staff 1 (S1) reported that the residents chose their new insurance and stated that the facility is here to protect the residents' Health and Safety. During the course of the investigation LPA reviewed documents including the Citrus Hills Assisted Living Health Care Change dated October 22, 2024, for R1. CONTINUED ON LIC9099-C... Unsubstantiated Per Health Care Change for R1 it states starting immediately we give our permission to have R1's health care management be rendered by Senior Doc personnel and their associates. The Health Care Change was signed on October 22, 2024, by R1's conservators. Documents reviewed included the Citrus Hills Assisted Living Health Care Change dated October 23, 2024, for R2. Per Health Care Change it states management company Gnosis Geriatric Wellness Center and it's associated persons and affiliates are required to stop all treatment, assessment and visitations. The Health Care Change was signed on October 23, 2024, by R2. LPA reviewed documents including the Citrus Hills Assisted Living Move In Record dated October 14, 2022, for R3. Per Move In Record R3's Primary Care Physician (PCP) is listed as Gerardo Canchola. Per National Provider Identifier Database Gerardo Canchola is listed as the Medical Director for Gnosis Geriatric Wellcare Center Inc. Regarding the allegation that Licensee has changed residents' health insurance for financial gain, the following was revealed: During the course of the interviews six of seven individuals denied the allegation and/or stated not being aware if the facility changed the residents' health insurance for financial gain. During the course of the investigation LPA observed that R1, R2 and/or their conservators signed a Health Care Change statement when changing their health insurance. During the investigation LPA observed that R3 has not changed their health insurance. During the course of the interviews with staff, S1 reported that the Licensee has not changed the resident's health insurance for financial gain and stated that the resident with a Power of Attorney (POA) had their POA signed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 22-AS-20241028095754

Allegation investigated: Facility does not have hot water

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannouced visit to conduct a 10 day visit. LPA was greeted and granted entry into the facility by Receptionist Cindy Mora and explained the reason for the visit. Administrator Charles Marinko arrived shortly after. The Department received a complaint that alleged the facility does not have hot water. During the visit LPA Mendivil toured the faciltiy with Maintenance Director Jesse Chrisman. LPA observed water tanks on the roof the facility. In addtion, LPA Mendivil interviewed staff and residents. Regarding the allegation that the facility does not have hot water, the investigation revealved the following: LPA Mendivil tested 2 out of 4 Spa Restrooms which contains 2 sinks and a shower, the other 2 spa bathrooms were occupied. Spa Bathroom on the first floor by Room 106 tested at 125 degrees for both sinks and 106 for the shower. Spa bathroom located on the second floor by room 217 the sinks tested at 119 degrees and 110 degrees with the shower testing at 100 degrees. Substantiated LPA Mendivil interviewed 4 residents, 4 out of 4 residents stated the water temperature is inconsistent as of 12/24/2024, but over the weekend on 12/21/2024 it was reported they did not have hot water in the restrooms. Based on interviews with 5 out of 5 staff indicated they were aware there was inconsistency with the water temperature. Administrator Charles Marinko stated they reached out to multiple plumbers and was able to reach a technician which specializes in the type of water heater the facility has. Administrator Charles stated the technician is scheduled to be at the facility today 12/24/2024. Administrator Charles stated they had a back up plan to take residents to a sister community if the shower issue persisted. LPA Mendivil observed the kitchen sink temperatures to be at 68 degrees. LPA Mendivil interviewed Dining Director Guillermo Sotelo which stated they have the ability to boil water and the dishwasher has its own water heater and therefore operational. Therefore based on the preponderance of evidence through observations and interviews the allegation facility does not have hot water is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20241223142646

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 30, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by the kitchen sink does not have hot water. The facility is still able to boil water for cooking, this poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 24, 2024

Plan of correction: Administrator indicated they have a technician who is going to maintenance the water heaters. Administrator to send proof of kitchen sink temperature by POC due date of 12/30/2024.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjunction with complaint visit for complaint control 22-AS-20241223142646. LPA Mendivil toured the facility with Maintenance Director Jesse Chrisman and observed the following: LPA Mendivil tested 2 out of 4 Spa Restrooms which contains 2 sinks and a shower, the other 2 spa bathrooms were occupied. Spa Bathroom on the first floor by Room 106 tested at 125 degrees for both sinks and 106 for the shower. Spa bathroom located on the second floor by room 217 the sinks tested at 119 degrees and 110 degrees with the shower testing at 100 degrees. Per interview with Administrator Charles Marinko a technician is coming out to the facility on 12/24/2024. Based on interviews with 4 out of 4 residents stated that the hot water is inconsistent and can "flash" to cold and then back to hot. LPA Mendivil tested hot water in kitchen sink which read at 68 degrees. Administrator Charles stated they will provide a sign to advise residents of the water temperature in sinks is over 125 degrees. Therefore based on observations deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Dec 30, 2024

(e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature... ... attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by water is not maintained at regulation temp. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Dec 24, 2024

Plan of correction: Administrator has placed signs at the sinks that are over 125 degrees in addition a technician is scheduled to maintenance water heater on 12/24/2024. Administrator to provide proof to LPA by POC due date.

Allegation investigated: Staff did not prevent outbreak of bedbugs. Staff damaged and did not return resident’s personal belongings.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on September 10, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Charlie Marinko. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff did not prevent outbreak of bedbugs and staff damaged and did not return resident’s personal belongings. Resident 1 (R1) was admitted to the facility on April 29, 2022. Documents reviewed included the Physician Report (LIC602) dated April 29, 2022 for R1. Per Physician report R1’s diagnosis is Lumbar stenosis. Regarding the allegation that staff did not prevent outbreak of bedbugs, the following was revealed: During the investigation LPA reviewed documents including the Terminix Commercial invoices dated January 30, 2024, to July 03, 2024. Per Terminix Commercial invoice during these visits Terminix conducted a general pest control inspection. Documents reviewed included the Pestprotection Pest Control invoices dated June 10, 2024, CONTINUED ON LIC9099-C... Unsubstantiated to September 11, 2024. Per Pestprotection Pest Control dated June 10, 2024 it states inspect entire 1st floor and 2nd floor for bedbug activity to determine where the bedbugs are active. Per Pestprotection Pest Control dated June 14, 2024 it states vacuum entire unit cracks and crevices, bed frames, baseboards and apply a treatment for the control of bedbugs where live bedbug activity was detected. Per Pestprotection Pest Control dated September 18, 2024 to December 06, 2024 it states apply crawling insect prevention to the interior and exterior perimeters of the building and/or applied bedbug control. During the course of the interviews with residents, R2 reported that they have not seen bedbugs in the facility and stated that the exterminator comes monthly. Regarding the allegation that staff damaged and did not return resident’s personal belongings, the following was revealed: Documents reviewed included the Resident Personal Property and Valuables (LIC621) dated May 03, 2022 for R1. Per Resident Personal Property Valuables R1's personal property include an Insignia television, two cellphones and a wheelchair. During the course of the interviews, R1 reported that in April 2024 the facility brought in professional exterminators and stated that they bagged his clothes while inspecting his unit. Per R1 staff lost 11 of his shirts, shorts and socks. LPA reviewed documents including the Citrus Hills Assisted Living A/R Change Form dated January 11, 2024. Per A/R Change Form R1 received a discount/credit for $299 for personal items. Per R2 staff have not damage or taken his personal property. R2 reported that he has not had issued with staff and stated that staff are helpful. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, this allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with ED, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 22-AS-20240910121745

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to conduct and initial investigation on complaint investigation #22-AS-20241114102450. LPAs met with Executive Director (ED) Charlie Marinko and explained the purpose for the visit. During the inspection visit, LPAs noted the following deficiency not related to complaint investigation. During a tour of the physical plant, LPAs inspected resident room 105. LPAs observed that the closet doors in resident room 105 were dismantled and not in their appropriate position. Based on the observations made during today's visit, there is 1 Type B deficiency being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Charlie Marinko. A copy of the report and Appeals Rights were provided.the state’s words, verbatim · CDSS document, Nov 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 4, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: During a tour of the physical plant, LPAs inspected resident room 105. LPAs observed that the closet doors in resident room 105 were dismantled and not in their appropriate position. This poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 20, 2024

Plan of correction: Executive Director (ED) Charlie Marinko stated he will repair or replace the closet doors in resident room 105 by POC due date. ED will email LPA Saborit-Guasch a photo of the closet doors once they have been replaced or repaired.

Type of visit: Required - 1 Year

On today’s date, Licensing Program Analysts (LPAs) Samer Haddadin and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPAs met with Executive Director administrator (ED) Charles Marinko. This facility is licensed to provide services to residents age range 60 and over. Approved for 95 non-ambulatory residents, of which 12 may be bedridden and has an approved hospice waiver for 20 residents. At time of visit, facility had total of 85 residents in which 5 are currently on hospice. LPAs observed smoke detectors/carbon monoxide in common areas, hallways, and bedrooms; all were tested on August 22, 2024, by Fire Safety Services Inc Fire. Fire extinguisher were fully charged with service tag indicating last inspection date was on November 13, 2023. Fire drills are conducted quarterly with last drill conducted on September 30, 2024. Residents’ bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets were observed to be operational, grab bars were secure. Water temperature was tested in first spa room and measured at 106.8 degrees Fahrenheit. The second spa room, on second floor, measured at 106.5 degrees Fahrenheit; Resident’s one (R1) restroom water temperature measured at 107.7 degrees Fahrenheit; Resident’s (2) restroom water temperature measured at 107.7 degrees Fahrenheit. On or about 9:41 AM, LPAs toured the kitchen area with ED and noticed multiple food items that were expired; one gallon of Reliance Heavy Duty Mayonnaise expired on September 24, 2024; one gallon of Reliance Mustard expired on September 11, 2024. One gallon of Coleslaw Dressing expired on August 28,2024. LPAs checked for 2-day supply of perishable, 7-day supply of non-perishable foods and emergency water; all were observed in today’s visit. Kitchen appliances were observed to be operational with sharps and knives being inaccessible to residents in care. (CONTINUE LIC 809C)... LPAs toured the backyard of the facility and observed there was a shaded seating area and ample space for activities; all outside emergency exists were free of tripping hazards and or obstructions or barriers. LAPs observed exit stairwells and each floor had an evacuation chair. Toxins were locked and inaccessible to residents. Medications were locked and inaccessible to residents. First aid kit had all the required elements including bandages, tweezers, thermometer, scissors, and manual. LPAs reviewed 8 residents’ files and observed all files had all required documentation. LPAs also reviewed 4 staff files and observed all had the required documentation. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were provided to AD at end of inspection.the state’s words, verbatim · CDSS document, Nov 1, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit to the facility for the purpose of following up on citation issued on LIC form 809D on 10/23/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87464(f)(4)) pertaining to Basic Services- Medication has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 28, 2024

Allegation investigated: Resident sustained pressure injuries while in care Facility staff did not notify resident's physician about changes in resident's condition

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as hospice records. Regarding the allegations that facility staff did not notify resident's physician about changes in resident's condition and resident sustained pressure injuries while in care, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 04/06/2019 with an initial hospice admission on 12/25/2020 for protein calorie malnutrition. Resident re-certified for hospice 03/17/2021. Hospice records and physician report dated 03/30/2021 indicated resident had multiple skin tears. Hospice documentation shows resident was being seen multiple times a week from 12/25/2020-05/29/2021. Wound care was being provided. Hospice documentation dated 02/08/2021 indicated half rails and fall pads were ordered for the resident. Hospice documentation is signed by hospice physicians indicating the CONTINUED ON LIC 9099C DATED 10/23/2024 Unsubstantiated physician was aware of the resident's condition at the time. Based on record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 22-AS-20210623133139

Allegation investigated: Staff are not properly trained

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as training records. Regarding the allegation that staff are not properly trained, the investigation revealed the following: LPA reviewed training records for Staff 1 (S1). LPA observed required training hours including required medication training. Based on record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfounded the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility. *This is an amended report to reflect "Unsubstantiated."the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 22-AS-20211105101618

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 24, 2024

Basic services shall at a minimum include: Personal assistance and care as needed by the resident, with those activities of daily living such.. assistance with taking prescribed medications,..This req is not being met as evidenced by: Based on record review, Licensee failed to ensure resident was provided assistance with taking medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee to provide an in-service on medication administration and forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in-conjunction with complaint visit 22-AS-20210623133139. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the complaint investigation, LPA reviewed Resident 1's (R1) file. Resident did not have an updated physician report. Physician report dated 12/06/2018 indicates a diagnosis of Dementia. Based on the observations made during today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiency. Exit interview conducted and a copy of this report was provided along with appeal rightsthe state’s words, verbatim · CDSS document, Oct 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Nov 6, 2024

Each resident with dementia shall have an annual medical assessmentt, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This req is not being met: Based on record review, Licensee failed to ensure R1 received an updated physician report due to diagnosis of Dementia. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 23, 2024

Plan of correction: Licensee to provide an in-service on ensuring residents with Dementia have updated physician reports and forward proof to LPA by POC due date.

Allegation investigated: Facility staff are not providing a clean and sanitary environment for residents in care. Facility staff are not ensuring that resident grab bars are safe for residents in care. Facility staff are not keeping the facility free of insects.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPAs were greeted and granted entry into the facility and met with Receptionist Cindy Mora. LPAs explained the reason for the visit. Administrator (AD) Itzayana Barba Aguirre was notified by staff via telephone. This agency has investigated the complaint alleging that facility staff are not providing a clean and sanitary environment for residents in care, facility staff are not ensuring that resident grab bars are safe for residents in care and facility staff are not keeping the facility free of insects. Regarding the allegations, the following was revealed: During the course of the interviews six of eight individuals interviewed denied that staff are not providing a clean and sanitary environment for residents in care. During the course of the interviews with residents, Resident 1 (R1) reported that it could be better and stated that staff clean their bedroom and CONTINUED LIC9009-C... Unsubstantiated During the course of the interviews with staff, Staff 1 (S1) reported that some screen doors are broken. Per S1 a couple of resident have complained and stated that the maintenance director is fixing the issue. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff are not ensuring that resident screen doors are in good repair is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit. bedding daily. Per R1 the facility is pretty much clean all the time and reported that the new cleaning lady cleaned their restroom and it looks amazing. During the initial visit LPAs observed as housekeeping staff were cleaning bedrooms on the first and second floor. Regarding the allegation that facility staff are not ensuring that resident grab bars are safe for residents in care, the following was revealed: Six of eight individuals interviewed denied the allegation. During the initial visit LPAs toured random restrooms throughout the facility and observed that grab bars were in good repair. During the course of the interviews R1 reported that they use the grab bars all the time and stated that the grab bars are in good condition. Per R2 the grab bars are fine. During the course of the interviews with staff, Staff 1 (S1) reported that the grab bars are safe and stable for the residents' use. Regarding the allegation that facility staff are not keeping the facility free of insects, the following was revealed: Four of eight individuals interviewed denied the allegation. During the course of the interviews R2 stated that she has not seen insects or bugs. Per R3 he has not seen insects or bugs. During the course of the investigation LPAs reviewed documents including the Pestprotection Pest Control dated August 27, 2024. Per Pest Control report the following was done apply crawling insect prevention to the exterior perimeter of the building, treat the interior of building common areas, restroom areas, storage areas, spa rooms and inspect 7 units at the time of service. Based on the information gathered during the investigation and review of documents obtained, LPAs are unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, this allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPAs conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 22-AS-20240925145424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 17, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations and interviews with the resident some screen doors do not open/slide and/or are in disrepair. This poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Licensee to repair all screen doors and email POC proof to LPA by POC date.

Allegation investigated: Facility does not provide nutrious, well balanced meals.

Regarding the allegation: Facility does not provide nutritious, well balanced meals. 10 of 10 individuals interviewed were unable to corroborate the complaint allegation. All the residents interviewed know they have an alternative menu available to them and if they don’t like whats being served they can request something else. 3 of the residents interviewed stated if they don’t want what the kitchen is serving, they will go and buy themselves something to eat, and all three of the residents who made that statement are aware they can order off the alternative menu as well.1 resident that was interviewed said, the food is terrible, but said it’s not the staff’s fault, they do the best they can. It’s the material they use. Staff 2 (S2) explained how the alternative menu works and stated 10:30 am is the cut off time for lunch and 3:30 is the cut off time for dinner. S2 stated it’s easy to prepare something for breakfast, but if the resident wants something like a breakfast burrito, they need to order the night before. 2 staff members who were interviewed think the food is of good quality and stated they eat the food sometimes. Continued on LIC9099C Unsubstantiated Based on the information gathered during the investigation through interviews, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 22-AS-20240820120724

Allegation investigated: Facility is allowing Residents to smoke in non-designated smoking areas.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to investigation a complaint received August 20, 2024. LPA Haley was greeted by staff and explained the reason for the visit before entering the facility. The complaint investigation consisted of interviews with facility staff, residents, document review and observation. Regarding the allegation: Facility is allowing Residents to smoke in non-designated smoking areas. 3 of 10 individuals confirmed the complaint allegation, including one resident who admitted to smoking outside on the patio area outside the resident’s room. The resident stated they never smoke inside the room. During the interview the resident walked outside to shoe LPA Haley where the resident smokes at. While on the patio, LPA Haley observed several cigarette butts in two different areas on the patio. Photos were taken. Continued on LIC9099C Substantiated Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 22-AS-20240820120724

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 6, 2024

87468.1- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: LPA Observations and interview confirmation from a residents who admitted to smoking right outside their room on the patio area/space available to the resident. The area the resident smokes in is not a designated smoking area. This presents a potential health, safety, and personal rights to resident in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Executive Director Barba Aguirre stated she will read and review the Regulation Section 87468.1 on Personal Rights of Residents in All Facilities and send a signed statement of acknowledgement and understanding. ED Barba Aguirre will also send a statement on what will be done to prevent this from happening in the future. POC will be emailed to LPA Haley by 12 noon on the POC due date.

Allegation investigated: Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the allegation listed above. LPA met with Ryan Mims the maintenance supervisor and explained the reason for the visit. The investigation into the allegation revealed the following. It was alleged that the facility got rid of Resident 1's (R1) clothes without their approval or knowledge. R1 reported that his clothes went missing around the time he went to the hospital and when he returned his clothes were gone. The Administrator reported that staff was told to wash the clothes. The maintenance supervisor reported that he told housekeeping to wash the residents' clothes in hot water and then to return them to the residents. The maintenance supervisor reported that they do not know what housekeeping did with the clothes. LPA verified on the facility visit on June 6, 2024 that R1 did not have any clothes in their room. Resident 2 (R2) reported that staff told him they threw out R1's clothes. Staff 1 reported that they were told by management to throw away the clothes of R1 because of the bed bug issue. Staff 1 reported that R1's clothes were thrown away. R1 reported he thought he heard staff mention his clothes were thrown away but doesn't remember who said it or when they said it. R1 reported the facility provided them new clothes, Substantiated on June 19, 2024 when they returned to the facility. Based on the evidence gathered through interviews, the preponderance of evidence standard has been met, therefore the allegation is deemed substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 22-AS-20240530105511

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Jun 21, 2024

12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requirement was not met as evidenced by... R!'s clothes were thrown out by the facility without there knowledge and permission. This poses an immediate Health and Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Licensee agrees not to throw out resident's belongings without their consent. Licensee agrees to train all staff on CCR 87468.1 and to submit proof of training to the LPA.

Allegation investigated: Staff did not ensure facility was kept free of bedbugs

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Itzyzna Aguirre and explained the reason for the visit. The investigation into the allegation staff did not ensure the facility was kept free of bed bugs revealed the following. It was alleged that the facility did not address the issue of bed bugs being present in resident rooms at the facility. LPA interviewed staff and residents at the facility. LPA and the Administrator toured the facility. LPA did not observe any bed bugs or any insects in the facility or the rooms that were alleged to have bed bugs. On May 1, 2024 Resident 1 (R1) reported they saw bed bugs in their room. The maintenance director reported they were notified about the bed bugs on May 1, 2024 and they called the pest control company to the facility to treat the room. A review of facility records shows that the room in question was treated by the pest control company for bed bugs on May 2, 2024. The Administrator reported that after this was reported she ordered staff to check each room. It was discovered after the first room was treated that 2 other rooms were in need of treatment. The review of records shows that after bed bugs were reported in the other rooms staff called the pest control company Unfounded to have the rooms treated. The invoices provided by the facility show both rooms were treated the day after the report of bed bugs. The facility documents show the facility has monthly pest control service. The last service was provided on May 7, 2024. Staff reported that the next service should be on June 7, 2024. The Administrator reported that on June 10, 2024 the entire facility will be checked by the pest control company and any rooms found with bed bug activity will be treated. This information was verified with an invoice from the Pest Control Company, The Administrator reported that after the first report of bed bugs the facility began the search to find the best company to inspect and possibly treat the whole facility. None of the witnesses interviewed knew how the bed bugs go into the facility. LPA observed that residents who had their rooms treated for bed bugs had new beds and all of their clothes were washed. Staff reported and residents interviewed verified that after the rooms were treated for bed bugs they were cleaned by staff before residents moved back in. LPA observed during the visit that new mattresses are stored in secured packaging that includes the mattress being sealed in plastic before they are used. It is unclear how the bed bugs made it into the facility. What is clear is that the facility addressed the issue in a timely manner and took steps to have the bed bugs removed once they were reported. The facility is being proactive and making an effort to ensure there are no more bed bugs at the facility. Based on the information provided the allegation is deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jun 6, 2024 · control 22-AS-20240530105511

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on a self-reported incident regarding stolen medication. The incident report was received by Community Care Licensing (CCL) on April 29, 2024. LPA was greeted and allowed entrance into the facility by Administrator (AD) Itzayana Barba Aguirre. LPA explained the reason for the visit. LPA conducted a toured of the inside and outside of the facility as well as bedroom of Resident 1 (R1). Incident report dated April 26, 2024 states that on April 22, 2024 R1 missed a dose of their medication due to another resident taking their bubble pack. During today's visit LPA reviewed documents including the Citrus Hills Assisted Living In-Service trainings dated April 22, 2024 and April 25, 2024 on how to lock and unlock the medication cart/how to ensure medication carts are locked/what to do if a narcotic count is off. Per AD the facility has also implemented a Plan of Action to prevent medications from being stolen in the future. AD reported that the Plan of Action will include that the Medication Technician (MT) keeps the keys with them at all times, the MT will double check that the medication cart is locked before stepping away and the MT will do a medication count at the end of every shift. During' today's visit LPA observed the MT passing out medication. LPA observed as the MT locked the medication cart before stepping away. An exit interview was conducted with AD Barba and a copy of this report was provided at the time of this visit.the state’s words, verbatim · CDSS document, Jun 6, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to conduct a case management visit in conjunction with complaint visit 22-AS-20240223161833. LPA was greeted and granted entry into the facility and met with Administrator (AD) Itzayana Barba Aguirre. LPA explained the reason for the visit. During today's visit LPA reviewed resident documents and conducted interviews with a resident and staff. LPA Ramirez conducted an exit interview with AD Barba, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Staff did not seek timely medical attention for a resident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 23, 2024. LPA was greeted and granted entry into the facility and met with receptionist Cindy Mora. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff did not seek timely medical attention for a resident. Resident 1 (R1) was admitted to the facility on July 28, 2023. Documents reviewed included the Physician Report (LIC602) dated July 27, 2023 for R1. Per Physician report R1 is able to communicate their needs. During the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated January 17, 2024 for R1. Per UIIR on January 12, 2024 R1 had an unwitnessed fall and R1 was helped up. Per UIIR wound care was completed on R1's skin tear. During the course of the interviews with residents, R1 reported that she has not had a fall that made her head bleed. Per R1 is she needed to go to the Hospital staff would call 911. CONTINUED ON LIC9099-C... Unsubstantiated R2 stated that he has not needed medical attention and reported that if he did that staff would call 911. During the course of the interviews with staff, Staff 1 (S1) stated that if a resident's head is bleeding that staff would call 911. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 15, 2024 · control 22-AS-20240223130422

Allegation investigated: Staff do not assist resident with meeting medical needs

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 23, 2024. LPA was greeted and granted entry into the facility and met with receptionist Cindy Mora. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff do not assist resident with meeting medical needs. Resident 1 (R1) was admitted to the facility on September 27, 2022. Documents reviewed included the Physician Report (LIC602) dated March 27, 2024 for R1. Per Physician report R1's diagnoses are hemiplegia and bullous pemphigoid. Per the Mayo Clinic bullous pemphigoid is defined as a rare skin condition that causes large, fluid filled blister. During the course of the interviews with witnesses, Witness 1 (W1) reported that during an assessment on April 4th, 2024 that she did not noticed boils all over R1's body. During the course of the interviews with residents, R2 reported that she has not develop rashes or wounds and stated that staff would assist her if she needed to get medical attention. CONTINUED ON LIC9099-C... Unsubstantiated During the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated February 28, 2024 and March 8th 2024 for R1. Per the first UIIR on February 26, 2024 an ambulance was scheduled for R1 and R1 was transported to the ER for skin alteration. Per the second UIIR on February 29, 2024 Home Health Nurse recommended for R1 to be sent to the Hospital for skin alteration. Records reviewed by LPA included the Unison Health Services Home Health Plan of Care dated February 29, 2024 to April 28, 2024. Per Plan of Care Home Health staff will instruct on disease process of cellulitis and hemiplegia management and prevention of disease exacerbation and potential complications and importance of prompt reporting to the Primary Care Physician (PCP). Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 15, 2024 · control 22-AS-20240223161833

Allegation investigated: Staff did not ensure resident’s room is adequately cleaned.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA Ramirez was greeted and allowed entry into the facility and met with Maintenance Director Ryan Mims. LPA explained the purpose of the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Eight of nine individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the Resident Admission Agreement dated 07/28/23 for Resident 1 (R1). Per Admission Agreement for R1 under Basic Services number 1.1.8. it states weekly housekeeping, to include vacuuming of carpets, mopping of floors,...and emptying the trash. Per Basic Services under 1.1.9. clean bed and bath linen weekly. Records reviewed by LPA Ramirez included the Housekeeping Log for R1. CONTINUED ON LIC9099-C... Unsubstantiated Per Housekeeping Log R1's bedroom is being cleaned more than once per week. During the interviews with residents, R1 reported that their bedroom is cleaned and stated that the Housekeeping staff is a good person. Per R1 their bedroom does not smell like urine and/or feces. During the interviews with staff, Staff 1 (S1) reported that she cleans R1's bedroom daily and stated that she takes out the trash daily. During the initial visit on 03/01/24 LPA observed that R1's bedroom was adequately cleaned and observed that the trash cans were empty. During the initial visit LPA toured R1's bedroom and did not smell any malodorous smells. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with facility representative and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 22-AS-20240223130422

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on February 6, 2024. LPA spoke to Yairell Garcia, Wellness Director and explained the reason for the visit. Incident report indicated that on January 26, 2024, at about 6:00pm, staff on shift were notified by residents sitting out front of the facility that resident (R1) had left the community. The wander guard system alarm did not notify staff that resident had left the community. Staff checked the community and surrounding areas. R1’s wife and 911 was called to make a report. At 6:30pm R1 was located by Administrator and Wellness Director, R1 was making their way back to the community and resident indicated they just went for a walk. Staff evaluated R1 and observed no medical treatment was necessary and had no injuries. During today’s visit LPA spoke to Wellness Director who confirmed details of the incident reported. LPA observed resident throughout the facility and observed residents in the front of the facility as well. LPA reviewed R1’s records and observed physicians report indicates R1 is able to leave the facility unassisted. R1’s primary diagnosis hemipelagic and hemiparesis following cerebral infarction affecting right dominant side, secondary diagnosis is hearing loss, depression, psychosis, seizures and insomnia. Physicians report does indicate dementia however it is not a primary or secondary diagnosis. Due to this reason facility as a safety precaution has a wander guard on R1, physicians report/resident appraisal/care plan do not indicate that R1 has wandering behavior. Facility staff immediately took the following measures facility checked resident wander guard and it was functioning, however facility still changed the wander guard for a new one and had an Inservice training provide to all facility staff. Even though R1 was able to leave the facility unassisted, facility took the appropriate measure because R1 did not check out of the facility prior to leaving. Resident remains at the facility safe, and no further incidents or issues reported. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 20, 2024

Allegation investigated: Facility staff who are not skilled professionals are performing glucose testing on resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as medication administration record. Regarding the allegation that facility staff who are not skilled professionals are performing glucose testing on resident, the investigation revealed the following: Resident 1 (R1) requires glucose testing. Physician report dated 08/31/2022 indicated resident is able to manage medications as well as perform own glucose testing. However, two out of three med techs as well as resident confirm staff is assisting with glucose testing. Staff are not appropriately skilled professionals. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with the Appeal Rights were provided at the time of this visit. Substantiated Resident indicated morning medications are administered with food and the staff administer the medication with the resident's breakfast. However, R1 stated that the resident prefers to take medications unobserved and without staff present. R1 denies refusing medications on this instance or any occasion. Three out of three staff deny allowing resident to walk out of sight with medications and residents are required to take the medication in front of the staff. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Feb 6, 2024 · control 22-AS-20240129094914

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Feb 7, 2024

The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens..., or has it administered by an appropriately skilled professional. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure glucose testing is performed by an appropriately skilled professional. Staff are performing glucose checks on R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 6, 2024

Plan of correction: Licensee to conduct an in-service to staff and forward proof to LPA by POC due date.