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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004718
Report Date: 06/27/2025
Date Signed: 06/27/2025 05:10:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241227090733
FACILITY NAME:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:100CENSUS: 70DATE:
06/27/2025
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Wendy Cruz - Executive Director TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not prevent a resident from sustaining injuries while in care.
Staff did not prevent a resident from suffering multiple falls while in care.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on December 27, 2024, and the initial 10-day visit was conducted on December 30, 2024. The Department obtained copies of documents including physician’s reports, needs and services, and admission agreements. Regarding the allegations, Staff did not prevent a resident from sustaining injuries while in care and Staff did not prevent a resident from suffering multiple falls while in care, the investigation revealed the following:

Resident 1 (R1) was admitted to the facility on October 27, 2024. Per physician report dated October 09, 2024, R1 has a diagnosis of mild cognitive impairment and motor impairments. R1 was receiving assigned 1:1 care through the Veterans Affairs office two to three times weekly for a couple of hours in the mornings. R1 was assessed to be a fall risk and had sustained six falls within a two month period of time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20241227090733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718
VISIT DATE: 06/27/2025
NARRATIVE
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On October 27, 2024, R1 tripped while getting up from their bed and slipped on the side of their bed. R1 sustained a scrape to their right arm and shoulder. The facility notified R1’s family and nurse practitioner.

On November 04, 2024, R1 fell while walking out of their room. During the incident, R1 hit their head on a bench in the hallway. The fall was witnessed by a nearby caregiver. Staff called 9-1-1. R1 was later diagnosed with a subdural hematoma which was determined to be non-operative. R1 was discharged back to the facility after a couple of days of observation in hospital. R1’s family and nurse practitioner were notified of the incident. On November 07, 2024, the resident was seen by their home health nurse who notated the resident got multiple abrasions on the right side of their eye socket and a black eye.

On November 27, 2024, while being assisted by their 1:1 caregiver, R1 tripped and sustained a fall while walking into the facility. Paramedics were called by staff and R1 was assessed to not require further medical attention. Two witnesses interviewed later reported caregivers found teeth on the floor and discovered R1 had missing teeth. The facility notified R1’s family and nurse practitioner.


On December 11, 2024, R1 sustained an unwitnessed fall in front of their recliner. Staff observed R1 had two small scratches on their back but did not complain of pain and was observed able to walk. R1’s family and nurse practitioner were notified and first aid was applied.

On December 13, 2024, R1 sustained an unwitnessed fall next to their bed. Caregivers heard R1 yelling for help. R1 did not push their pendant or complain of pain. Facility staff monitored R1 for any further changes of condition. 9-1-1 was not called however facility notified resident’s nurse practitioner.
On December 18, 2024, R1 sustained a second fall while being escorted to the bathroom by a caregiver. Per interview with caregiver 1 (C1) they were closing the front door and trying to get into the bathroom when R1 fell. C1 observed R1 fall toward the shower. C1 called the facility Residential Care Director (RDC). Per interviews conducted, R1 was bleeding from their shoulder and lip. 9-1-1 was called and tended to R1’s injuries on their arm. R1 was admitted to St. Joseph Hospital Orange where they were diagnosed with acute on chronic intracranial subdural hematoma. Neurosurgery was consulted and recommended nonoperative management. Resident remained hospitalized until December 22, 2024.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20241227090733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718
VISIT DATE: 06/27/2025
NARRATIVE
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Per records reviewed, the facility did not conduct a reassessment after R1’s falls despite having numerous conversations with R1’s family. R1’s family reported they had considered moving R1 to a board and care facility but was discouraged by facility RDC. R1’s family denied ever being provided options such as alarms or bedrails and was told by facility RDC bed alarms make too much noise and the caregivers would be running around. The facility provided R1 a call button; however, R1 did not know how to use it per interviews with staff.

On December 21, 2024, R1’s family notified the facility they would be moving R1 out of the facility after being discharged from the hospital and placed on hospice.

Therefore, based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. The allegations that Staff did not prevent a resident from sustaining injuries while in care and Staff did not prevent a resident from suffering multiple falls while in care are deemed substantiated.

A civil penalty is pending determination, per H&S Code Section 1569.49(f).

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.
An exit interview was conducted and a copy of this report, LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC412IM and LIC811 were provided to the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20241227090733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/02/2025
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: Care and supervision… This regulation was not met as evidence by:
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Executive Director will conduct an inservice regarding assisting residents that are fall risks. Facility to provide proof of insevice to LPA by POC due date
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The Licensee did not provide care and supervision to resident due to R1 sustaining six falls over a period of 2 months resulting in multiple hospitalizations and subdural hematoma. This poses an immediate risk to resident in care. CIVIL PENALTY ASSESSED.
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Deficiency Dismissed
Type A
06/28/2025
Section Cited
CCR
87463(a)
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The appraisal…shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition…
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Executive Director to conduct inservices about changes in condition. Facility to provide proof of insevice to LPA by POC due date
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This regulation was not met as evidence by: The Licensee did not update resident’s appraisal to notate changes in condition and preventative measures after observing R1 sustaining six falls over a period of 2 months. This poses an immediate risk to resident in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20241227090733

FACILITY NAME:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:100CENSUS: 70DATE:
06/27/2025
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Wendy Cruz - Executive Director TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
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9
Staff did not seek medical attention for a resident in care.
Staff did not respond to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on December 27, 2024, and the initial 10-day visit was conducted on December 30, 2024. The Department obtained copies of documents including physician’s reports, needs and services, and admission agreements. Regarding the allegations, Staff did not respond to resident’s call button in a timely manner and Staff did not seek medical attention for a resident in care, the investigation revealed the following:

Resident 1 (R1) was admitted to the facility on October 27, 2024. Per physician report dated October 09, 2024, R1 has a diagnosis of mild cognitive impairment and motor impairments. R1 was receiving assigned 1:1 care through the Veterans Affairs office two to three times weekly for a couple of hours in the mornings. R1 was assessed to be a fall risk and had sustained six falls within a two month period of time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20241227090733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718
VISIT DATE: 06/27/2025
NARRATIVE
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R1 sustained a total of six falls over a period of two months. R1 sustained falls on October 27, 2024; November 04, 2024; November 27, 2024; December 11, 2024; December 13, 2024; and December 18, 2024. After each fall, R1 was assessed and the facility contacted either 9-1-1 or R1’s nurse practitioner. R1’s family was notified after each fall.

Interviews with four of five staff report staff respond to calls under five minutes; however, if staff are very busy it can take up to five to fifteen minutes to respond. Staff reported they felt there was sufficient staffing to respond to calls within a reasonable amount of time. If a resident is waiting more than a few minutes the Med Tech on duty will radio in and remind someone to check on the resident until the call light is turned off. Although R1 sustained multiple falls, the facility staff reported they called 9-1-1 when R1 sustained an injury.

Therefore, based on interviews conducted and records reviewed the allegations that staff did not respond to resident’s call button in a timely manner and staff did not seek timely medical attention are deemed to be Unsubstantiated.

An exit interview was conducted and a copy of this report and confidential names list was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6