306004718-4-6-2021-22-AS-SSAS-C292NK-20210419173251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004718
Report Date: 04/06/2021
Date Signed: 04/06/2021 12:48:16 PM

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
06/26/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200626161258

FACILITY NAME:	GROVES OF TUSTIN, THE		FACILITY NUMBER:	306004718
ADMINISTRATOR:	LIANA FOOTE		FACILITY TYPE:	740
ADDRESS:	1262 BRYAN AVE		TELEPHONE:	(714) 730-5009
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	100	CENSUS: 78	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Liana Foote - Executive Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility staff is refusing to release records to resident's POA

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez contacted the facility via telephone to conduct a subsequent complaint investigation visit telephonically due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez spoke with Executive Director (ED) Liana Foote, identified herself and discussed the above allegation.

On today's visit LPA requested copies of facility and resident records. LPA Velazquez also conducted interviews with facility staff. During the course of the investigation the following was revealed: LPA Velazquez reviewed resident records such as Resident (R) #1's Admission Agreement, Physician's Report, Preplacement Appraisal Information, Level of Care Assessment, Admission Orders, Power of Attorney documents dated and signed by R1 on June 18, 2020, Living Will and Advance Care Directive dated and signed by R1 on June 18, 2020, and Power of Attorney documents dated and signed by R1 on February 9, 2006. The individuals

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: 714-380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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-20200626161258

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: 04/06/2021

NARRATIVE

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interviewed provided conflicting statements where the above allegation could not be corroborated. One of R1's POA was subsequently provided with copies of R1's documents they had requested from the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation that Facility staff is refusing to release records to resident's POA is deemed unsubstantiated.

An exit phone interview was conducted with Executive Director Liana Foote and a copy of this report was signed by LPA Patricia Velazquez. This report along with the LIC 811s will be sent via email to Executive Director Liana Foote who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Executive Director Liana Foote agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to Executive Director Liana Foote.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: 714-380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

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