<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 05/28/2020
Date Signed: 05/28/2020 11:48:08 AM

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:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR:LIANA FOOTEFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:100CENSUS: 75DATE:
05/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Executive Director Liana FooteTIME COMPLETED:
11:50 AM
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
As precautionary measures during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made an unannounced teleconference call to Executive Director (ED) Liana Foote. LPA stated the purpose of the phone call, which was to conduct a case management for a reported incident in the facility.

On May 21, 2020, Community Care Licensing Division (CCLD) Orange Office received an incident report from the facility which stated that between 4:30 AM to 5:00 AM of May 21, 2020, Resident 1 was observed not in the apartment. Staff conducted an immediate search in and around the facility perimeter. Thereafter, facility activated 911; and filed missing person report. Resident 1 was found; and was brought to the hospital for evaluation and management.

For this visit, LPA Marin conducted a phone interview with ED Liana Foote. LPA sent out an email requesting for copies of pertinent documents to be reviewed in relation to the incident.

Due to insufficient information at this time, this case management will be completed at a later time.

LPA Marin conducted a phone exit interview and read the report to ED Liana Foote. LPA will provide a copy of this report via email; and in turn, ED agreed to acknowledge its receipt.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020
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 1