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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200275
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:13:30 PM

Document Has Been Signed on 06/10/2022 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GROVE WAY MANOR INC.FACILITY NUMBER:
019200275
ADMINISTRATOR:MARISSA LEGARDAFACILITY TYPE:
735
ADDRESS:927 GROVE WAYTELEPHONE:
(510) 397-0344
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Terrence Louie Da Anton/Staff TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Terrence Louie Da Anton, Nancy Da Anton and Romark Merjilla, and informed the purpose of visit. LPA called Marissa Legarda; no response. so LPA sent text message informing that LPA is at the facility to do inspection. Marissa authorized Terrence to be with LPA during inspection. Marissa arrived at 3:30 p.m.

Facility has an approved LIC808 Mitigation Plan on file.

LPA inspected the living room, dining area, kitchen, common bathroom, bedrooms, garage, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe and Visitor's Log. Visitor's temperature and symptom checks are done at entrance. Residents and staff are screened for COVID-19 symptoms and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. LPA observed trash bins with foot pedal operated lids and COVID-19 signages throughout the facility. Supplies of PPEs were checked. and observed adequate for 30 days. Four (4) staff were fit tested for N95 respirator and LPA obtained copies of test certificates. The rest of the staff are to be scheduled for testing.

Fire extinguisher checked and observed fully charge with tag showed serviced May 21, 2022. Hot water temperature in the common bathroom was tested and measured at 105,6 degrees Fahrenheit.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GROVE WAY MANOR INC.
FACILITY NUMBER: 019200275
VISIT DATE: 06/10/2022
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Administrator to submit copies of the following updated documents by June 24, 2022:
1. LIC308 Designation of Facility Responsibilit
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. N95 Fit Testing certificates of the 3 staff

LPA reminded that new Infection Control Plan should be submitted by June 30. 2022.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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