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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 02/10/2025
Date Signed: 02/10/2025 09:34:25 AM

Document Has Been Signed on 02/10/2025 09:34 AM - 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: DATE:
02/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Debbie Garibaldi - Resident Care Director TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry into the facility by Monica, Activities Director and explained the reason for the visit. Resident Care Director, Debbie Garibaldi arrived shortly after.

The Department received an Unusual Incident/Injury Report LIC 624 on 02/06/2025 for an incident that occurred on 01/29/2025. It was reported that around 4:55pm staff heard an alarm from a delayed egress door on the Northeast side. It was reported staff checked out the area and did not see a resident. Then staff conducted a resident head count and determined it was Resident 1 (R1) that was missing. Elopement protocol was initiated and staff began to look for R1 outside of the community and Tustin Police Department was called. Facility notified R1's responsible party and faxed over the information to R1's physician.

It was reported that R1 arrived at family's house and R1's family drove R1 back to the community. A body check was conducted and no injuries were noted. R1 did not complain of pain but stated they were tired.

The facility then placed a wander guard on R1 and frequent checks were added to the resident's care plan.

Per review of LIC 602 Physicians Report dated 12/23/2024 stated R1 does not have wandering behaviors and per Alma Gomez, Memory Care Director family stated R1 had not wandered off in the past.

Based on observations made a deficiency is being cited. An exit interview was conducted and a copy of this report was provided to facility representative.
Alisa OrtizTELEPHONE: (714) 703-4084
Andrea MendivilTELEPHONE: 714-703-2738
DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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 02/10/2025 09:34 AM - 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: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2025
Section Cited
CCR
87464(f)(1)

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(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).Health and Safety Code section 1569.2(c) provides c) "Care and supervision" ...
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Facility corrected prior to visit. Wander guard was placed on R1 and in service conducted on 2/5/2025. Facility to email in service signature to LPA by 2/14/2025
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..means the facility assumes responsibility for, or provides or promises to provide in the futureongoing assistance with activities of daily living. This requirement was not met as evidence by R1 was able to leave the facility unassisted. This poses an immediate safety risk to persons 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.
Alisa OrtizTELEPHONE: (714) 703-4084
Andrea MendivilTELEPHONE: 714-703-2738

DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025

LIC809 (FAS) - (06/04)
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