Citrus Place.

A follow up interview with R1 to gather further information could not be conducted due to R1’s passing. Interview with Staff 2 revealed that R1 had a family member who would direct R1 to not take certain medications and on one occasion observed the family member remove a pill from R1’s hand. Additionally, S2 noted that the family member would often contact for medical assistance when it wasn’t needed. A review of records corroborated statements made by S2. On April 24, 2020, the county conservator assigned to R1 contacted the facility and authorized a family member to speak with R1 twice a week for 10 minutes, with the calls to be supervised. Shortly after this communication, paramedics arrived at the facility, reporting that a family member had requested assistance. Upon assessment, paramedics determined that R1 was sleeping on the couch and did not require medical attention. On 4/26/2020, a family member called paramedics reporting that R1 was having a stroke. The fire department responded and assessed R1, determining that R1 appeared normal and stable throughout their assessment. Regarding the allegation facility staff yelled at resident it was alleged that a staff member was verbally aggressive with R1. AW1 reported that they were visiting R1 inside R1’s room when they overheard an individual loudly instructing R1 to shut the door. AW1 stated they did not leave the room and therefore could not confirm whether the voice belonged to a staff member or another client in care. AW1 could only speculate the voice may have been a staff member, describing it as deep and strong. Interview with staff 2 reported they had not observed any staff be verbally aggressive with R1. A review of records such as Special Incident reports and facility consumer notes did not reveal any reference to a complaint or incident relating to the allegation and R1. For the allegation that facility staff confiscated Resident's dog, it was alleged the facility confiscated R1’s dog in June of 2019. A review of records revealed a pet agreement was signed by R1’s representatives on 8/16/2017. Interview with Executive Director Megan Blacher reported that pets are allowed in Assisted Living, however, a policy is in place to ensure proper care. Executive Director Blacher noted that if a resident is incapable of properly caring for the pet, arrangements are made with family unless they decline and then proper authorities would be contacted for assistance. Interview with Staff 2 reported that R1 had a dog that was removed by a family member and not returned back to the facility. Interview with Additional Witness 1 was attempted and did not respond to multiple requests. Interview with R1 could not be conducted due to their passing. Interview with Witness 2 (W2) was attempted and did not respond to multiple requests. No further information could be obtained. Continued on LIC 9099-C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on interviews, record reviews, and observations, the allegations that staff alleging facility staff did not provide resident with requested medical aid, facility staff yelled at resident and facility staff confiscated resident's dog have been deemed UNSUBSTANTIATED. A finding that the 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. An exit interview was conducted. A copy of this report was provided to Executive Director Megan Blacher.

Interview with additional parties corroborated the information. Based on interviews and record review, the allegation that facility staff do not observe residents for change in condition is unfounded due to the listed residents not residing at the facility. A finding that the allegation is unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Connections for Living Director Megan Snell.

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Megan Blacher. The LPA informed the Executive Director of the purpose for the visit. The inspection included the following: The facility licensed with the department is comprised of a memory care unit and assisted living. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. All outdoor and indoor passageways are kept free of obstruction and debris. . LPA inspected 10 (10) client rooms and observed the required bed, chair, grab bars for each toilet, and shower used by residents. Resident showers have non-skid mats present. LPA began review of client records. eight (8) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, TB test results, needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. LPA reviewed employee records- eight (8) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 09/30/2026. LPA observed personnel records to be available and complete. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There is a locked room in assisted living and an additional locked room in memory care allocated for medication storage. Digital centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Multiple fire extinguishers were observed to be serviced on 10/02/2025. Emergency drills are conducted monthly at the facility with the last drill on 10/31/2025. Based on the information received during this visit today in the areas reviewed, there are no deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representative and a copy was provided.

It was advised that C1’s Power of Attorney requested that they are contacted first for non emergency incidents. POA indicated that they will have C1 assessed and determine if further medical evaluation is required. It was determined by POA that the injury to C1 did not require further medical attention. C1’s POA refused emergency medical personnel. At approximately 3 PM, facility staff observed the swelling to increase and medical personnel was contacted at that time. C1 was transported to the hospital to be further evaluated.  Information obtained from staff and additional witnesses corroborated the information and indicated that C1’s POA indicated they did not want C1 transported to the hospital. Due to the swelling increasing, medical personnel was contacted. Due to C1’s condition, LPA was unable to obtain additional information pertaining to the incident. Based on observation, record review, client, and staff interviews, it was determined that staff contacted C1’s POA immediately to advise of the injury and was advised not to contact emergency services, causing a delay. Staff continued to monitor and evaluate C1’s injury to assess if further medical evaluation was necessary. Facility staff did later contact medical personnel services where it was determined C1 needed to be transported.  Therefore, the allegation is unsubstantiated, means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was discussed with and provided to the Connections for Living Director Megan Snell.

select training records and all had documentation of required training hours . Nine out of nine staff interviewed deny caregivers yelling at residents or being abusive in any way. Two residents interviewed deny staff yelling at residents and confirm being treated well. Additional residents in Memory Care were unable to respond to the departments questioning. Facility provided all incident reports requested by the department including those reports for Resident 1 (R1) and R2 outlining any falls that have occurred. Nine out of nine staff deny being told to avoid speaking to the department or not reporting incidents. When conducting interviews with staff, staff was cooperative and communicative in discussions with the department. Based on interviews conducted and records reviewed, LPA is unable to corroborate the allegations. Therefore the allegations are deemed UNSUBSTANTIATED meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility representative.

On 11/21/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver amended complaint findings for complaint control numbers: 18-AS-20231013143500 and 18-AS-20230918160404. LPA met with Executive Director Vicky Torres where LPA explained the purpose of the visit. An exit interview was conducted and a copy of this report was provided to Vicky Torres, Executive Director.

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Vicky Torres. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: The facility licensed with the department is comprised of (2) buildings. Memory care which is a one story building and the assisted living facility is a two story. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential care facility for the elderly serving elderly ages (60) and above. LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 112.7 degrees F.All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. LPA inspected six (6) client rooms and observed the required bed, chair, grab bars for each toilet, and shower used by residents. Resident showers have non-skid mats present. LPA began review of client records. eight (8) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Partial documents were stored in a digital database needing multiple staff to locate and were not provided during a reasonable time frame. LPA waited over an hour to confirm the documents. LPA suggested to look into providing one complete digital file or paper file to be ready for review when needed. Administrator stated that all files will be printed and stored in one file. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA began review of employee records- nine (9) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 07/24/2025. LPA observed the same issue with personnel files with the facility having multiple staff keeping certain files. Administrator stated she just started earlier this year and will be auditing and updating the files to be accessible much easier and in one location. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There are two locked rooms allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA observed Fire extinguishers to be serviced and within compliance. The facility is conducting emergency disaster/fire drills monthly; last done on 10/04/2024. Based on the information received during this visit today in the areas reviewed, there are no deficiency that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with administrator Vicky Torres and a copy was provided.

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator Lori Spencer who was informed of the purpose of the visit. At the time of the visit the facility has (8) cases of residents who are positive for COVID-19, Personal Protective Equipment (PPE) and precautions were taken during the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents, and observed the following: The facility licensed with the department is comprised of (2) buildings. Memory care which is a one story building and the assisted living facility is a two story. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential care facility for the elderly serving elderly ages (60) and above. Infection Control: LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA observed facility residents in isolation who are positive for COVID-19 with PPE equipment outside their rooms, and meals that are being provided to their rooms. LPA was informed staff are encouraging resident to wear PPE and LPA observed staff wearing PPE while around the residents. The facility has reported the infectious disease to the department, and have a plan on mitigating the spread of infectious diseases. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The facility has carbon monoxide alarms which were located during the time of the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food supplies to meet resident's needs. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Record Review and Resident/Staff Files: LPA reviewed staff files, training, and staff criminal clearance, client files were also reviewed for memory care and assisted living residents. The administrator's file was reviewed which met the department requirements. All required and up to date paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room and medications carts. Medication was accounted for and LPA observed staff passing medications and observed the facility has the new cycle of medication for all residents. Centrally stored lists of medications for (5) residents were reviewed. Disaster preparedness: The facility has an emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 12/22/23. LPA observed all facility exits were clear from obstructions and the facility possess the required evacuation chairs at stairways. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Administrator, Lori Spencer.

During the time of the visit LPA conducted a tour of the facility and observed comfortable temperature in the facility lobby and attached dining area. LPA observed temperature reading 74F at the time of the visit on air conditioning display in facility lobby. At the time of the visit LPA observed residents in the dining area eating breakfast and did not observe any health or safety risks. LPA interviewed (5) staff during the time of the visit. LPA found that the staff confirmed the facility air conditioning was not working around the beginning of the month and the facility had placed fans and portable air conditioning units in the affected areas. All (5) staff stated that no residents had complained of the temperature and no residents were experiencing heat related symptoms. LPA was informed that the staff were monitoring the temperature in the facility during this time until the air conditioner was fixed to produce a comfortable temperature that did not drop below 84F. LPA was informed by staff that residents also were encouraged during this time to dine in their rooms where the air conditioning was working. LPA was informed by staff that there is a plan to get a component repaired and was provided an invoice for labor that is scheduled and was conducted when the air conditioning stopped working. Based on the above information the facility took steps to ensure the residents were provided with comfortable temperature and have a plan to fix the issue long term. Therefore the allegation is unsubstantiated. A finding that is unsubstantiated means the allegation may be valid, but the preponderance the evidence standard has not been met. An exit interview was conducted with the executive director over the phone and the staff, Megan Snell where this report was reviewed and provided to them.