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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:16:52 PM


Document Has Been Signed on 12/05/2022 02:16 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: 64DATE:
12/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mirella Manjarrez- Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit for an incident reported on 11/30/2022.

LPA Mendivil spoke to Mirella Manjarrez Executive Director regarding resident #1(R1). LPA explained that the purpose of this visit is to discuss a self reported incident report which occurred on 11/26/2022. Executive Director explained that resident 1 (R1) was found unresponsive at 5:50pm by a medication aide and was later pronounced deceased . Resident was found unresponsive on couch during PM medication pass. Paramedics did not perform any life saving measures as R1 was DNR.

Per staff 1 (s1) they asked R1 what R1 would like for lunch since R1 took their lunch in their room, R1 responded that they did not want lunch and waived S1 off. S1 then told staff 2 (s2) that R1 did not eat lunch, S2 stated they will check on him at 5:50pm during medication pass. S1 was then called into R1's room by S2. S1 stated it R1 was fully clothed with a case of beer next to him. S1 reported 911 was called.

Resident Care Director, Debbie Garibaldi stated she was called and told R1 had passed. Debbie reported that R1's sister indicated the cause of death is still pending and R1's remains have been released to mortuary.
R1's sister stated coroner report with cause of death with take some time

No deficiency cited during this visit per Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to Executive Director.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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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