306004718-10-9-2025-22-AS-APAO-DMQ4DZ-20251022190133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004718
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:31:31 PM

Unsubstantiated

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
07/19/2022 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20220719163920

FACILITY NAME:	GROVES OF TUSTIN, THE		FACILITY NUMBER:	306004718
ADMINISTRATOR:	MIRELLA MANJARREZ		FACILITY TYPE:	740
ADDRESS:	1262 BRYAN AVE		TELEPHONE:	(714) 730-5009
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	100	CENSUS: 70	DATE:	10/09/2025
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Wendy Cruz - Executive Director		TIME COMPLETED:	12:59 PM

ALLEGATION(S):

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Resident sustained injury due to neglect

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 faciltiy and explained the reason for the visit.

The Department received the complaint on 07/19/2022 and the 10 day visit was conducted by LPA Saborit-Guasch on 07/28/2022, and LPA Mendivil conducted a follow up visit on 09/08/2022. During the visits LPA obtained copies of resident physician report, service plan, progress notes, and hospital discharge paperwork. Regarding the allegation that resident sustained injury due to neglect, the investigation revealed the following:

It was alleged that Resident 1 (R1) sustained injuries due to neglect from multiple falls. Per R1's physicians report dated 06/16/2020 stated R1's diagnosis is end stage congestive heart failure and it was identified that R1 is a fall risk.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220719163920

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: 10/09/2025

NARRATIVE

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Per review of Unusual Incident/Injury Report for 09/24/2021 it was reported R1 was found on the floor by staff and was assessed, R1 did not complain of pain and was able to ambulate with walker. Per report both R1's physician and responsible party were notified. It was also reported that resident was placed on alert charting and service plan was updated.

Per review of Unusual Incident/Injury Report for 11/18/2021 it was reported R1 was found in the bathroom floor after R1 attempted to use the restroom. Per report R1 hit her head and 911 was called and R1 was assessed by paramedics but refused transfer to the hospital. Per report paramedics did not note any bumps on R1's head. R1 was placed on alert charting and mention of physical therapy and occupational therapy to continue to work with R1. R1's family and physician were notified and service plan was updated.

Per review of Unusual Incident/Injury Report for 04/18/22 it was reported R1 reported to staff that they had chest pains and R1 was sent out to the hospital. R1's family and physician were notified. R1 was admitted to the hospital until 04/21/2022 diagnosis was pneumonia, R1 was notified needed a stent replacement but declined surgery.

Per review of Unusual Incident/Injury Report for 04/21/2022 it was report R1 was found on the floor next to their bed by staff. R1 was noticed to have blood and bruised left eye and hand. 911 was called and R1's family and physician were notified. R1 was admitted to the hospital and returned to the community on 04/22/2022. Per report a 1:1 caregiver was put in place following hospital discharge.

Per Progress notes dated on 05/25/2022 it was reported R1's 1:1 caregiver notified staff that R1 had fallen and staff went to assess resident, during assessment R1 had purple lips, 911 was called. It was reported that staff notified R1's family and physician. R1 was admitted to the hospital until 05/28/2022.
R1 was admitted to hospice on 06/09/2022.

Per review of Unusual Incident/Injury Report for 07/17/2022 during rounds staff went to open R1's door but could not due to R1 blocking the door. Per report staff was able to access the resident's room via patio door. 911 was called and resident was taken to the hospital. R1's family and physician was notified.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220719163920

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: 10/09/2025

NARRATIVE

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R1 was discharged on 07/18/2022 and was placed on alert charting and admitted back into hospice.

Per review of Unusual Incident/Injury Report for 07/19/2022 it was reported that R1's room door was noted to be opened around 04:10am by staff and then around 4:55am the door was closed and staff entered the room and saw R1 on the floor. R1 was bleeding from their head 911 was called. R1's family and physician were notified. R1 was admitted to the hospital and did not return to the facility after discharge.

Per review of R1's service plan R1 was identified as a fall risk with mitigation such as clutter free pathways, staff assist to walk to and from to events, call pendant, and increased monitoring overnight for bathroom assist. Per review of progress notes dated 07/05/2022 R1's family discontinued 1:1 caregiver. Interviews with staff and witness stated R1 would get up on their own and ambulate and not call for assistance.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that Resident sustained injury due to neglect is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

No deficiencies cited.
An exit interview was conducted and a copy of this report and confidential names list was provided

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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