<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 03/24/2021
Date Signed: 03/25/2021 09:18:13 AM

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: 77DATE:
03/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:37 PM
MET WITH:Liana Foote, Executive DirectorTIME COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone as a follow up to a case management- incident via telephone due to COVID-19 and for pre-cautionary measures. LPA Chin identified herself and spoke to Liana Foote, Executive Director.

LPA, Kathrina Chin spoke to Liana Foote, Executive Director regarding resident #1(R1). LPA explained that the purpose of this virtual visit is to discuss a self reported incident report which occurred on March 24, 2021. Ms. Foote explained that resident 1 (R1) was found unresponsive at 7:18 am by a caregiver and was pronounced deceased at 7:26 am by a police officer from Tustin Police Department. Resident was found sitting in front of his computer and he had been drinking alcohol. Orange County Coroner's arrived and picked up the deceased for toxicology. The report will be released in one to three months per the resident's daughter.

No deficiency cited this review as per Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to Administrator via email. Liana Foote agreed to confirm the receipt of the document, review the report and return a signed copy.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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 1