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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:54:36 PM

Document Has Been Signed on 02/28/2025 04:54 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:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR/
DIRECTOR:		MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 100TOTAL ENROLLED CHILDREN: 0CENSUS: 66DATE:
02/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Alma Gomez - Memory Care Director TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management. LPA was greeted and granted entry by Alma Gomez and explained the reason for the visit.

On 02/28/2025 the Department received a Death Report (LIC 624A) for Resident 1 (R1). It was reported by the facilty that R1 was found deceased in their room by staff on 2/26/2025. Memory Care Director Alma Gomez called 911 and Tustin Police Department and paramedics arrived. Alma stated paramedics determined that R1 was deceased and Orange County Corners office arrived around 12:30pm and R1 was taken to the Corner's office.

LPA Mendivil obtained copies of preplacement appraisal, advance directive and Physician's Orders for Life Sustaining Treatment (POLST). LPA Mendivil toured the facility and residents were in the dining room for dinner.

No health or safety violations noted during today's visit.


Based on the observations made during today's visit, no violations noted. Exit interview conducted and a copy of this report was provided.
Alisa OrtizTELEPHONE: (714) 703-4084
Andrea MendivilTELEPHONE: 714-703-2738
DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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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