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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 07/30/2020
Date Signed: 07/30/2020 12:14:14 PM

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: 73DATE:
07/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Liana Foote - Executive DirectorTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPAs) Patricia Velazquez and Criss Trinidad contacted the facility via telephone to conduct a Case Management visit utilizing phone FaceTime virtual technology due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez spoke on the phone with Executive Director (ED) Liana Foote, identified herself and discussed the purpose of today's visit. The purpose of today's Case Management visit was to follow-up on a Confirmation of Removal letter for an individual Staff (S) #2 received by Community Care Licensing (CCL). Per ED Foote, S2 has not worked in the facility.

At 11:30 am LPAs Velazquez and Trinidad along with ED Foote conducted a virtual tour of the physical plant. LPAs and ED did not observe S2 present in the facility at the time of the visit.


Based on evidence obtained during today's visit, LPAs Velazquez and Trinidad have verified the individual (S2) is not present, employed, or residing at the facility. LPA Velazquez has advised ED Foote to disassociate the individual from their roster and submit an updated LIC 500. ED Foote indicated to LPA that the facility received the Confirmation of Removal documentation from the California Department of Social Services, Community Care Licensing Division, Caregiver Background Check Bureau (CBCB) regarding individual (S2) and their Criminal Record Clearance on July 22, 2020. ED Foote indicated S2's last day of work was 7/20/2020 and was formally terminated as of 7/27/2020. ED Foote will provide termination documentation to LPA Velazquez.

There were no deficiencies issued during today's Case Management visit. An exit phone interview was conducted with ED Liana Foote and a copy of this report along with the LIC 811 were signed by LPA Patricia Velazquez and sent via email to ED Liana Foote who then agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. ED Liana Foote agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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