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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200275
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:55:24 PM

Document Has Been Signed on 06/13/2024 03:55 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/
DIRECTOR:		MARISSA LEGARDAFACILITY TYPE:
735
ADDRESS:927 GROVE WAYTELEPHONE:
(510) 397-0344
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Marissa Legarda/Administrator and
Rudy 'RJ' Golilao/House Manager		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, June 13, 2023, at 11:10 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Randall Cabading. 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. Administrator arrived at 11:46 a.m., followed by another staff, Rudy 'RJ' Golilao.

Facility submitted the Infection Control Plan on June 24, 2022.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced August 8, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. Hot water temperature in the resident's room was tested and measured at 112.6 degrees Fahrenheit. Facility conducts fire drills monthly, and records showed last conducted May 26, 2024.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 staff. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I checked and compared with last recorded balance.

LPA observed the following:
-from 12:50 p.m. to 1:15 p.m., all 5 residents do not have LIC9172 Functional Capability Assessment on file. -at 2:00 p.m., R2 has Risperdal (2 mg 1 tab BID) listed on LIC602 Physician's Report but facility does not have this medication nor have discontinued order on file.
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.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 06/13/2024
NARRATIVE
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-R2 has 2 new medications (Senna 8.6 mg and Docusate Sodium 100 mg) filled on 5/31/24 but not listed on LIC622 Centrally Stored Medication and Destruction Record

Administrator submitted copies of the following current/updated documents on this same day:
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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/13/2024 03:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/13/2024 at 03:28 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above inR2 having Risperdal (2 mg 1 tab BID) listed on LIC602 but facility does not have this medication nor have discontinued order on file which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Administrator to obtain discontinued order if the medication is no longer needed; otherwise, obtain the medication, Proof to be submitted by 6/14/24.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/13/2024 03:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/13/2024 at 03:28 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

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 cited above in 5 out of 5 residents not having LIC9172 Functional Capability Assessment on file. which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Administrator stated she'll do the the LIC9172 and self certify they are completed. Self-certification to be submitted by 6/27/24.
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 record review, the licensee did not comply with the section cited above in not having the 2 medications of R2 listed on LIC622 which poses a potential personal rights risk to person in care.
POC Due Date: 06/27/2024
Plan of Correction
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Corrected.
Staff recorded the medications.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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