331881323-10-12-2022-18-AS-TDAN-CK5NJY-20221012103103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881323
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:31:46 AM

Document Has Been Signed on 10/12/2022 10:31 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GROVE CARE ASSISTED LIVING, THE		FACILITY NUMBER:	331881323
ADMINISTRATOR:	ESPINOZA, BRIANA		FACILITY TYPE:	740
ADDRESS:	3401 LEMON STREET		TELEPHONE:	(951) 686-8202
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY:	66	CENSUS: 0	DATE:	10/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Briana Espinoza, Administrator		TIME COMPLETED:	10:10 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation due to a change of ownership. LPA met with Administrator (AD) Briana Espinoza. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 2/15/2022 for a total capacity of 66 residents, 28 of which may be non-ambulatory. Fire Clearance was granted on 7/21/2022. The following was observed during today's visit: Structure: Facility was a seven story building housing assisted living residents on the 3rd, 4th, and 5th floors only. The other floors house independent residents and skilled nursing residents which are not licensed by the Department. Heating/Cooling System: Central heating and air conditioning system installed with control panels located in various areas of the facility. The air temperature throughout the facility was noted to be comfortable. Bedrooms: All resident bedrooms were adequately furnished with bed, chair, appropriate linens, adequate lighting, and were decorated with resident's personal belongings. Bathrooms: Resident bathrooms are equipped with working toilets, wash basins, and showers with non-skid materials and grab bars. At 9:12AM, LPA began testing water temperatures in various resident rooms which measured 110.9, 115.6, and 117.4 degrees Fahrenheit. Kitchen: Sufficient storage for perishable food as well as non-perishable food was observed. The freezer and refrigerator temperatures were maintained within regulatory requirements. The stove was observed to be operational. There was adequate seating for meals for all residents in the main dining room. Knives/sharp instruments were not observed to be accessible to any resident. (CONTINUED ON LIC 812C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GROVE CARE ASSISTED LIVING, THE	FACILITY NUMBER: 331881323
	VISIT DATE: 10/12/2022

NARRATIVE

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(CONTINUED FROM LIC 812)
Living room space:
There were various adequate living room/group areas with safe and adequate seating for a number of residents to utilized at any given time. There was a salon available for residents as well. LPA observed staff assisting residents in the physical therapy room.
Yards/Outside:
There were partially shaded and fully shaded outdoor areas available with seating. A putting green was availble for resident use as well. All walkways were observed to be free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required in several areas of the facility.
General items:
Numerous fire extinguishers were located throughout the facility along with emergency lighting. The main fire control panel indicated all smoke alarms were operational. Resident records are stored in locked offices and/or locked cabinets. First Aid kit with required components was inspected in the med room. Locked medication carts are utilized for quick mobilization for medication distribution. Laundry equipment is in full use. Facility has a working telephone and passenger vans are available to transport residents.

Component III was completed during today's visit and a hard copy was provided as well for future reference.

Pre-licensing is complete and this facility has no deficiencies.

Licensure will be granted based on final approved from CAU. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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