CITRUS GARDENS

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 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 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

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

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

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.