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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200275
Report Date: 06/10/2023
Date Signed: 06/10/2023 06:49:44 PM

Document Has Been Signed on 06/10/2023 06:49 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:
06/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mariisa Legarda/Administrator and
Rudy 'RJ' Golilao/House Manager		TIME COMPLETED:
06:50 PM
NARRATIVE
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On this day, June 10, 2023, at 11:30 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Romark Merjilla, LPA spoke over the phone with Marissa Legarda, administrator, and informed the reason for visit. Administrator authorized Romark Merjilla to be with LPA during inspection. LPA also met with other staff, Nancy Da Anton, Nathaniel Anis and Rudy 'RJ' Golilao. Administrator arrived after about 50 minutes.

Facility has approved LIC808 Mitigation Plan, and submitted the Infection Control Plan on June 24, 2022.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living areas, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced May 5, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. Hot water temperature the resident's room was tested and measured at 110 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted May 27, 2023.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents and 2 staff. Medications were checked and compared with records. Residents' P&I reconciled with records.



......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2023
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: 06/10/2023
NARRATIVE
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LPA observed the following
-At 4:15 pm, the expiration dates of resident (R1) medications listed on LIC622 Centrally Stored Medication and Destruction Record do not match the dates on the medication labels.
-At 4:30 pm, expiration dates of resident's (R2) 3 medications listed on LIC622 do not match the dates on the labels.
-At 5:10 pm, resident (R5) has cough med administered but not listed on most current doctor's order on file. R5 also has vitamin administered once day but has 2 doctor's order/list of meds dated 5/01/23 where on 1 is not listed and listed on the other.

Administrator to submit copies of the following updated documents by June 24, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with the administrator and house manager.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.





SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/10/2023 06:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/10/2023 at 06:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GROVE WAY MANOR INC.
FACILITY NUMBER: 019200275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 5 residents having cough medication administered but not on the current order of medications. This resident also has vitamin administered once day but has 2 doctor's order/list of meds dated 5/01/23 where on 1 is not listed and listed on the other; it's not clear whether or not this vitamin is still needed. These pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 06/11/2023
Plan of Correction
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Administrator to check with the doctor's if the said medication and vitamin are still needed, and obtain updated list of doctor's order; otherwise obtain discontinued order. Proof to be submitted by 6/11/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/10/2023 06:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/10/2023 at 06:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GROVE WAY MANOR INC.
FACILITY NUMBER: 019200275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
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-Based on records review, the licensee did not comply with the section above in 2 out of 5 residents's expiration dates of medications incorrectly listed on LIC622 which pose a potential personal rights risks to persons in care..
POC Due Date: 06/24/2023
Plan of Correction
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Administrator to correct the records, and submit self-certifcation by 6/24/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023


LIC809 (FAS) - (06/04)
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