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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:55:19 PM


Document Has Been Signed on 03/27/2024 04:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR:MIRELLA MANJARREZFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:100CENSUS: 63DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Liana Foote, Executive DirectorTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Rose Ruppert, Michael Tea and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit on this day for the purpose of conducting an Annual Required Evaluation. LPAs and LPM were greeted and granted entry. During today’s visit, LPAs and LPM met with Liana Foote, Executive Director.

The facility is a three- story building with an approved fire clearance of 100 non-ambulatory residents of which 30 may be bedridden. The facility currently has a census of 63 residents in care.

LPAs and LPM reviewed 10 of 54 staff records; one staff member is missing fingerprints. LPAs and LPM reviewed 10 of 63 resident records. LPAs and LPM confirmed that administrator has a current administrator certificate which expires on 1/30/2025.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

Due to time constraints LPAs and LPM to return at a later date to complete inspection.

An exit interview was conducted with Liana Foote and a copy of this report was given to the facility along with a copy of the LIC 858; 859;809-D and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 2


Document Has Been Signed on 03/27/2024 04:55 PM - 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
ORANGE COUNTY RO, 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs and LPM record review, the licensee did not ensure staff #7 was fingerprint cleared. This poses an immediate safety risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee to send staff member #7 for fingerprinting on 3/28/204.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2