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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:33:35 PM


Document Has Been Signed on 03/30/2022 03:33 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
CCLD Regional Office, 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: 73DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mirella ManjarrezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was screened upon entry into the facility. LPA met with Executive Director MIrella Manjarrez and reason for the visit was explained. ED Manjarrez confirmed there are currently no cases or exposures of COVID-19 within the facility. ED Manarrez' Administrator Certificate expires on 05/23/2022.

LPA toured the facility with ED Manjarrez. LPA observed facility is currently having the entrance/hallway carpet replaced with new carpet. Precautions have been taken to keep the Residents safe during this transition. Facility has 73 Residents in care during today's visit with 13 Residents receiving Hospice care. Facility consists of Assisted Living with a Memory Care on the 2nd floor. LPA observed kitchen, Therapy Room, Salon, and the Parlor/Activity Room. LPA observed Residents relaxing, walking around and/or waiting for lunch. Residents appeared happy and well taken care of. Facility appears clean and sanitary. Resident rooms had the required elements as well as common bathrooms were stocked with soap/sanitizer/paper towels. Rooms are single occupancy in Assisted Living and some private and double occupancy in Memory Care. Visitors are screened using a questionnaire. LPA observed the screening/sanitizing station at the entrance of the facility. Facility utilizes an electronic temperature check and has a sign-in log sheet. Facility takes resident and staff temperatures daily and documents. First Aid kit has all required items. Mitigation Plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed multiple outside visitation areas. LPA observed the Medication Room and facility uses electronic medical records for medication management. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files durinvg the visit and files are up to date including emergency information. Most residents and staff are vaccinated for COVID-19. All required Department poster were observed. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report will be emailed to ED.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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