Incident reporting
Cited in 3 reports, with 3 deficiencies in total.
CITRUS GARDENS
25911 STANFORD ST, Hemet CA 92544
64 bedsLatest official report Apr 27, 2026Licensed
Additional info
- Telephone
- (951) 925-7107
- Licensee
- CITRUS GARDENS LEASING LLC
- Administrator
- TRACY LANGENDOEN
- Contact
- TRACY LANGENDOEN
- License first date
- Jul 27, 2015
- License effective date
- Jul 27, 2015
- District office
- RIVERSIDE ASC · (951) 248-2222
- Regional office
- 18
- Clients served
- 935 - ELDERLY
Summary
The available records show 10 Type A and 21 Type B deficiencies for this facility.
- Most recent inspection
- Apr 8, 2026
- Most recent deficiency
- Dec 5, 2025
10 later reports, from Mar 20, 2026 through Apr 27, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 54 Riverside County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 45 reports for this facility: 16 inspections, 29 complaint investigations, and 0 licensing or administrative records.
Those records contain 10 Type A and 21 Type B deficiencies.
4 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 16
- Recorded deficiencies
- 31
- Type A deficiencies
- 10
- Type B deficiencies
- 21
- Substantiated complaints
- 9
- Repeated topics
- 4
More than the typical 7
3 in the last 12 months
Well above the typical 3
5 in the last 12 months
Well above the typical 1
0 in the last 12 months
Well above the typical 2
5 in the last 12 months
Well above the typical 1
4 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Staffing, personnel, and training
Cited in 3 reports, with 3 deficiencies in total.
Admission, assessment, and eviction
Cited in 2 reports, with 2 deficiencies in total.
Resident rights
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 1 unfounded · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Mar 20, 2026 · Control 18-AS-20250619155106
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Incident reportingType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jan 9, 2026
Correction not verified in available records
Dementia careType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Dec 26, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Oct 17, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Resident rightsType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2025
Correction not verified in available records
Staffing, personnel, and trainingType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Oct 13, 2025
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Sep 19, 2025
Correction not verified in available records
Incident reportingType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Sep 12, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 25, 2025
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited · investigated over 2 visits
Admission, assessment, and evictionType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 12, 2025
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jul 29, 2025 · Control 18-AS-20221223121913
Basic services and supervisionType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline May 19, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Not classified in the sourceType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Sep 29, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 1 unfounded · 1 cited
Resident rightsType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jun 23, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Dementia careType A
- 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 record says corrected or clearedOn or before May 23, 2023
Correction deadline recordedDeadline May 24, 2023
Complaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Oct 5, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded · 1 cited
Background checksType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Dec 29, 2021
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology