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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004718
Report Date: 04/10/2024
Date Signed: 04/10/2024 05:00:30 PM

Document Has Been Signed on 04/10/2024 05:00 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GROVES OF TUSTIN, THEFACILITY NUMBER:
306004718
ADMINISTRATOR/
DIRECTOR:		MIRELLA MANJARREZFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVETELEPHONE:
(714) 730-5009
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 100CENSUS: 62DATE:
04/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Liana Foote, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea and Rose Ruppert and Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to the facility today to conduct a continuation Annual Random/Required Evaluation. LPA was greeted and granted entry by Alma Gomez, Memory Care Director. During today’s visit, LPAs and LPM met with Liana Foote, Executive Director.

The facility is a Residential Care Elderly triple story building with an approved fire clearance of 100 ambulatory; 100 non-ambulatory residents of which 30 may be bedridden with a hospice waiver for 10. The facility currently has a census of 62 residents/clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in 9 of 62 resident bathrooms, and testing auditory devices on all exits, if applicable. The hot water temperature measured between 96.9 and 119,4 degrees F and all smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review completed medication appear to be being given as prescribed.

LPA reviewed 10 of 10 staff training; During inspection LPAs and LPM were unable to determine number of hours of training due to facility not having access to database. Per administrator, during the change of management, records held by previous management company were made inaccessible upon their exit. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Liana Foote and a copy of this report was given to the facility along with a copy of the LIC 858; 859;809-D and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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Document Has Been Signed on 04/10/2024 05:00 PM - It Cannot Be Edited


Created By: Michael Tea On 04/10/2024 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above in 1 out of 10 resident rooms. In Resident 1's room, LPA observed sharp tools and cleaning wipes were accessible to R1 who has dementia which poses an immediate health and safety risk to person in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee's representative states the tools were removed and the wipes were given back to the daughter of the resident 1 during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2024 05:00 PM - It Cannot Be Edited


Created By: Michael Tea On 04/10/2024 at 04:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306004718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(h)
Personnel Records
(h) All personnel records shall be retained for at least three (3) years following termination of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in 9 out of 10 staff files, record of training staff hours were inaccesible. Per adminstator, files were removed by previous management company. Which pose a potential safety risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Licensee's representative stated will provide current training for 9 individual staff files chosen.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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