CITRUS GARDENS

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements 87211(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). Welfare and Institutions Code section 15630(b)(1) provides in pertinent part: Any mandated reporter who… has knowledge of an incident that reasonably appears to be…neglect…shall report the known or suspected instance of abuse by telephone … a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days.

Official plan of correction

Executive director will provide in house training on requirements to submitting SOC 341 form. Training will include the telephone resource for CCLD and LTCO to submit within 24 hours when applicable. ED will submit an updated weekend procedures to be in compliance with SOC 341 reporting requirements. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that the facility failed to submit properly submit incident under the SOC 341 Elder Abuse requirements. This poses a potential health safety or personal rights risk to residents in care.

Deadline recorded: Jan 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(3)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that the facility staff failed to intervene with resident elopement and is unaware on how they eloped. This poses a potential health safety or personal rights risk to residents in care.

Official plan of correction

Executive Director will provide me their security clearance procedures. Additionally, in house training will be provided to all staff on proper supervision procedures for residents in care and intervention procedures when observing potential elopement.

Deadline recorded: Dec 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1…elderly shall have …the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review, the facility is not staffed sufficiently at night from 10pm to 6am to meet night supervision needs.

Official plan of correction

The Licensee has corrected the issue. On 10/13/25 an updated LIC 500 and Staffing schedule was submitted to satisfy the plan of correction. The staff rotational procedure for supervision and the reported active residents during the night led to an altercation that staff did not witness or intervene. This poses a potential health safety or personal rights risk to residents in care.

Deadline recorded: Oct 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in 87468.1…elderly shall have …personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review, the facility is not staffed sufficiently at night from 10pm to 6am to meet night supervision needs.

Official plan of correction

The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care. The staff rotational procedure for supervision and the reported active residents during the night led to an altercation that staff did not witness or intervene. This poses a potential health safety or personal rights risk to residents in care.

Deadline recorded: Oct 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)

Regulation authority

CCR

What the official deficiency says

Night Supervision: 87415 (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures… to assist in caring for residents in the event of an emergency. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that staff failed to assist during an emergency involving a physical altercation between two residents. Staff were unavailable to provide timely intervention, resulting in injuries to both residents.

Official plan of correction

The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care. The lack of sufficient overnight supervision from 10:00 p.m. to 6:00 a.m. contributed to the incident occurring without staff presence or response. This poses a potential health safety or personal rights risk to residents in care.

Deadline recorded: Oct 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements: 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met, as evidenced by:

Official plan of correction

Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date. Based on LPAs record review and interviews, licensee did not ensure that the facility has sufficient staffing to provide the necessary services and supervision, this poses an immediate health and safety risk to the residents in care.

Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

REPORTING REQUIREMENTS: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman... licensing agency, & the local law enforcement agency within 24 hours as required by 15630(b)(1). This requirement was not met, as evidenced by: Based on a record review, 6 out 6 incidents, that met LTCO reporting requirements, were not cross reported by facility staff, per Title 22. This poses a potential health and safety and personal rights risk to residents in care.

Official plan of correction

Administrator will conduct in-service training on LTCO mandated reporting requirements under AB1411, including guidance on completing and submitting Form SOC 341 to ensure compliance.

Deadline recorded: Sep 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility…(4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as evidenced by: Based on observation, interview and record review, Medication was not administered as prescribed by physician, on two of two occasion to residents, which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will provide LPA with a planned procedure in place to properly dispense medication in the case of a call out by a MedTech. The plan must include weekend and NOC shift instructions on how coverage and medication dispensing will be followed. Administrator must provide training on the procedure with management and MedTechs. An email will need to be provided to LPA by POC date.

Deadline recorded: Aug 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(1)(E)

Regulation authority

CCR

What the official deficiency says

87463(1)(E) ReappraisalsSignificant changes in condition, as...Definitions, include,...limited, (E)Illness or injury...ignificant change in the health care or dietary needs of the resident. Based on the evidence the Administrator did not comply with the section cited above by staff not properly reporting, observing and or documenting the changes in R1's condition which resuled in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons in care.

Official plan of correction

Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Administrator will submit an email with a statement knowledging the regulation cited.Proof of staff reading over section 87463(1)(E) and completion of training to LPA Farlow by Plan of Correction (POC) due date.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in two out of eight staff files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Executive Director will email LPA the completed Health Screening with TB test results for the three discussed employees by POC date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in two out of eight resident records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction Executive Director will email or FAX LPA the signed Admissions Agreement for the two discussed residents by POC date.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 The licensee shall ensure residents are regularly observed ..changes in physical, mental, emotional and social... appropriate assistance...bservation reveals unmet needs...changes such as unusual weight gains or losses or deterioration of mental ability..physical health condition are observed..licensee shall ensure that such changes are documented and attention of the resident's physician and the resident's responsible person Based on the evidence the licensee did not comply with the section cited above by staff not properly caring for R1's wound resulting in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons in care.

Official plan of correction

Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Licensee will submit an email and statement of documentation of proof of staff reading over section 87466 and completion of training to LPA Farlow by Plan of Correction (POC) due date.

Deadline recorded: May 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

1. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on observation, interview, and record review, the facility administration did not comply with the section cited above in one out of one incident between two clients, which posses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will conduct a staff training on mandating reporting, guidelines, and the resources available for reporting. Administrator will email proof of completion of training and attendance sheet for all staff.An SIR will need to be submitted to CCLD for incident.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in one out four buildings that did not have a signal sytem in place. LPA observed call buttons in multiple resident bedrooms used for the facility's signal system to be missing. The LPA observed no signal system device set up for building two. According to staff, it was unknown where the device was moved to. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Onsite Administrator stated a new signal system will be obtained and proof will be submitted by the POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a...record is maintained for each resident in the facility or in a central administrative location readily available...to licensing agency staff. This requirment was not met as evidenced by: Based on interview, the facility did not have file for R1 readily avaible for licensing review. This poses a potential health, saftey or personal rights risk to residents in care.

Official plan of correction

The administrator agreed over the phone to send the documents to the LPA's email by the POC due date.

Deadline recorded: Jan 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

873099(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met, as evidenced by the following. Based on observation, the facility did not ensure to store cleaning solutions inaccessible to clients.

Official plan of correction

The Licensee shall provide training on the cited regulation section to all facility staff. The Licensee shall also provide proof of training with all employee signatures to the Regional Office (RO) by the POC due 09/29/2023.

Deadline recorded: Sep 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted... (3)The license shall submit these fingerprints to the California Department of Justice...prior to the individual's employment, residence, or initial presence in the facility. This requirement was not being met as evidenced by: Licensee did not ensure S1 obtained a criminal record clearance prior to beginning working at facility. Based on record review and interview, S1 had been working at the facility since 08/13/21. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee removed S1 from the facility. POC has been cleared.

Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to LPA observing blood in toilet and feces on toilet seat in Villa #1, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Facility agreed to provide staff training regarding infection control practices and precautions. Proof of correction to be submitted to CCLD by close of business on POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to the water damage and leakage in Villa #1's restroom in front of room 102, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Facility agreed to contact maintenance person to make necessary repairs to stop water damage/leakage in Villa #1 restroom in front of room 102. Facility stated restroom shower will not be used until repairs are made. Proof of correction to be submitted to CCLD by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above due to Staff #1 (S1) not having first aid/CPR training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Facility agreed to submit proof of S1's first aid/CPR training to CCLD by close of business on POC due date.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following rights: (8) To have their representatives regularly informed...of activities related to care or services...as appropriate to their needs. This requirement wasn't met, as evidenced by: Based on records & interview, the Licensee didn't ensure R1's representative was informed of R1's injury. A Narrative Report revealed R1 was observed w/ a blister & notes don't document notification to R1's representative. R1's representative reported having no knowledge of the blister. This posed a potential threat to R1's personal rights.

Official plan of correction

The Administrator will conduct a policy change to ensure the responsible parties of residents who receive additional services from hospice agencies will also be notified by the facility. The Administrator stated a copy of the change will be provided.

Deadline recorded: Jun 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements: (b) The following food service requirements shall apply:(5) Meals shall consist of an appropriate variety of foods..This requirement was not being met as evidenced by: Staff interview indicated that multiple meal alternatives were not available to be provided to residents in care. This poses a potential personal rights risk to residents in care.

Official plan of correction

Licensee held a staff meeting with their Culinary Director and supplied proof of converstation about ordering the items listed on the menu. POC cleared at time of visit.

Deadline recorded: May 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

8746.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(8) To be free from neglect...this requirement was not being met as evidenced by: Based on LPA observation, Resident did not have a call button that was working to alert staff of their needs. This poses a potential personal rights risk to residents in care.

Official plan of correction

Licensee fixed the call button and LPA saw that it functions properly. POC cleared at time of visit.

Deadline recorded: May 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not being met as evidenced by: Based on observation, LPA found that there was not a working auditory device which would alarm staff if a resident were to leave the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Upon visit, LPA observed auditory device installed as well as a combination lock installed on the door. POC cleared on visit.

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by: Based on record review and interview, the Licensee did not comply with the above regulation with one resident (R1). NOC shift staff observed R1 to have a bump on their head after an unwitnessed fall but did not contact emergency services. This was an immediate health & safety risk to R1.

Official plan of correction

Licensee agrees to retrain all care staff (and MedTechs) regarding policy on when to call 911 and for assessing residents after an unwitnessed fall. Licensee ot provide LPA Colvin with estimate on when all care staff will complete training by Plan of Correction date of 10/5/22. Licensee to additionally provide LPA Colvin with copy of signautres of all staff trained and their position at the facility.

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(b)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by: Based on observation the Licensee did not comply with the above regulation with at least one staff (S1). LPA George learned that S1 is not associated to this facility. This is an immediate safety risk to all residents in care.

Official plan of correction

Licensee agrees to associate staff #1 to the facility by 5/24/22, in order to continue to have S1 work at the facility. Licensee to provide LPA George with proof of submitted request by 5pm on the due date indicated.

Deadline recorded: May 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements... This requirement is not met as evidenced by LPA making the request and having to wait for 40 minutes. This is a potential health, safety or personal rights risk.

Official plan of correction

The licensee agrees to conduct an inservice on Resident records. Proof is to be submitted by 5pm on the due date indicated.

Deadline recorded: Jun 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted... (3)The license shall submit these fingerprints to the California Department of Justice...prior to the individual's employment, residence, or initial presence in the facility. Licensee did not ensure S1 obtained a criminal record clearance prior to beginning working at facility. Based on record review and interview, S1 had been working at the facility since 08/13/21. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will immediately remove staff from facility, and submit proof of background clearance submission by 12/29/21.

Deadline recorded: Dec 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not being met as evidenced by: LPA Gardner observed two screws securing the door shut. This poses an immediate health and safety risk to residents in care.

Official plan of correction

This deficiency was corrected at time of visit. The screws were removed, and a new number code lock was installed.

Deadline recorded: Oct 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - Facility personnel shall at all times be sufficient in numbers.... Additional staff shall be employed as necessary to perform.. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services... This requirement was not being met as evidenced by: LPA Gardner the staffing schedule on the dates for the two incidents and found staffing was absent in the area of the incident. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit staff schedule for next 30 days, and submit statement of understanding that staff has read and understand regulation 87411(a) and will comply

Deadline recorded: Nov 5, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

All personnel shall be given on the job training or have related experience in the job assigned to them. (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not being met as evidenced by: During a review of records, LPA did not observe any Emergency Intervention training for staff when a resident leaves the facility. This poses an potential health and safety risk to residents in care.

Official plan of correction

Licensee to provide training of staff and update the Emergency Intervention Plan to include a section on what staff needs to do when a resident leaves the facility on their own and submit by email to LPA by 11/4/21.

Deadline recorded: Nov 4, 2021. A deadline is not proof that correction was completed.