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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200275
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:58:12 PM

Document Has Been Signed on 02/21/2025 03:58 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: 6DATE:
02/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Marissa Legarda/Administrator and
Rudy 'RJ' Golilao/Assistant Administrator 		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, 2/21/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Special Incident Report (SIR) for resident (R1) submitted by the facility and received by LPA on 2/20/25. LPA met with staff, Randall Cabading and informed the reason for visit. LPA called and spoke over the phone with Marissa Legarda, administrator (ADM). Rudy 'RJ' Golilao, assistant administrator (AADM) arrived at around 11:45 am. ADM arrived at around 12:45 pm.

SIR indicated that on 2/19/25 that at around 4:00 pm, R1 with the 2 staff, came back to the facility after buying food. R1 became restless and asked the staff if he can leave by himself because he needs weed. Staff told R1 he can't leave by himself until his team allows him. R1 was told to take a deep breath or play basketball. R1 played basketball in the backyard with staff, S1 and S2, watching him. R1 then ran outside through the side door. S1 followed R1 but could not catch up. S1 drove around with other staff, S2, and found R1; however, R1 threw stones to the staff and to the van. Other staff also drove around looking for R1 while the other staff called BACS staff who told them to call the police. At 10:00 pm, Sheriff (SO) Officer came to the facility and asked for information and called R1's mother who informed SO that R1 is at temporary shelter in Oakland.

LPA reviewed R1's file and conducted interviews. LPA obtained copies of including but not limited to the following R1's documents: LIC603 Pre-placement Appraisal; hospital After Visit Summary; Medication Administration Record; E-Script Prescriptions


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/21/2025
NARRATIVE
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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 corrections were discussed with the ADM and AADM.

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: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/21/2025 03:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/21/2025 at 02:07 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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2025
Section Cited
CCR
85068.2(b)

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85068.2 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.......
-This requirement is not met as evidenced:
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Administrator to do the following and submit proof by 2/08/25:
1. Complete the LIC625.
2. In-service the staff and ensure the Needs and Services Plan is followed.
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-Based on record review, the licensee did not comply with the section above in not completing the LIC625 Appraisal/Needs and Services Plan which posed an immediate risks when R1 ran away from the facility.
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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: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


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Document Has Been Signed on 02/21/2025 03:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/21/2025 at 03:09 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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
88888

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85069.3 Mental Health Intake Assessment : (a) In order to determine his/her ability to provide the services needed by a client with mental illness,.......The administrator of an adult residential care facility that provides
services for residents shall ensure that a
written intake assessment is prepared by a
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Administrator to obtain assessment and submit a copy by 3/07/25.
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licensed mental health professional prior to acceptance of the client.
-This requirement is not met as evidenced by:
-Based on record review, the licensee did not comply with the section above in not obtaining the mental health assessement for R1.
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Type B
03/07/2025
Section Cited
CCR80069(b)

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80069 Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

-This requirement is not met as evidenced by
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Administrator to call the doctor to schedule an assessment. Copy of LIC602 to be submitted by 3/07/25.
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-Based on record review, the licensee did not comply with the section above in not obtaining the medical assessment for R1.
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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: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


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