306004517-1-6-2025-22-AS-SHAD-DCNVKL-20250106153032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004517
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:30:37 PM

Document Has Been Signed on 01/06/2025 03:30 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CHERI GROVE		FACILITY NUMBER:	306004517
ADMINISTRATOR/ DIRECTOR:	MARIA GO		FACILITY TYPE:	740
ADDRESS:	1171 CHERI DRIVE		TELEPHONE:	(562) 694-4507
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:50 AM
MET WITH:	Marissa Acerbo, Darlyn Colesio		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with staff Marissa Acerbo and discussed the purpose of the inspection. Administrator (AD) Darlyn Colesio arrived during the inspection. LPA reviewed Infection Control requirements. At about 12:30PM, LPA and staff Acerbo conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 6-bedroom, 3-bathroom, two-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents and a pool that is properly gated. LPA observed 4 staff and 4 residents present at the facility. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA observed three staff bedrooms on the second floor. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested 117 degrees F in the resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:30PM, LPA reviewed 4 resident files and 4 staff files, interviewed 4 residents and 3 staff, and inspected medications for 4 residents. Facility does not handle resident money. CONTINUED.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

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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Document Has Been Signed on 01/06/2025 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHERI GROVE	FACILITY NUMBER: 306004517
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure S1's staff file contained documented evidence of the required 20-hour annual training, which poses a potential safety risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee stated they will complete and document S1's required training and submit proof to LPA by POC due date.

Section Cited

Incidental Medical and Dental Care Services

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and admission, R1 is being given supplements including calcium with no doctor's orders on file and is not being given medications including Acetaminophen without discontinuation orders and R2 was not given their iron and vitamin C supplements after December 2024 despite the doctor's order not being discontinued, which poses a potential health risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee stated they will obtain up-to-date medication lists from the residents' doctors, accurately track medication administration for residents, and submit proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Armando J Lucero	TELEPHONE: (714) 703-2840
Sean Haddad	TELEPHONE: (714) 335-7094
	DATE: 01/06/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHERI GROVE	FACILITY NUMBER: 306004517
	VISIT DATE: 01/06/2025

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During the inspection, LPA and AD observed the following: based on documents, the licensee did ensure Staff #1’s (S1) staff file contained documented evidence of the required 20-hour annual training; and based on documents and admission, Resident #1 (R1) is being given supplements including calcium with no doctor's orders on file and is not being given medications including Acetaminophen without discontinuation orders and Resident #2 (R2) was not given their iron and vitamin C supplements after December 2024 despite the doctor's order not being discontinued.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025

LIC809 (FAS) - (06/04)

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