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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881323
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:47:23 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240826103259
FACILITY NAME:GROVE ASSISTED LIVING, THEFACILITY NUMBER:
331881323
ADMINISTRATOR:MORA, MICHELLEFACILITY TYPE:
740
ADDRESS:3401 LEMON STREETTELEPHONE:
(951) 686-8202
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY:66CENSUS: 66DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kip McMillan, Administrator in TrainingTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff do not provide services as agreed in the resident's Admission Agreement
Staff are not administering resident's medication
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator in Training, Kip McMillan, and informed him of the purpose for the visit.

A report was received alleging facility staff have failed to assist Resident One (R1) with setting up and being transported to their medical appointments. The investigation included staff and resident interviews, a review of records and collection of relevant documentation. R1 was interviewed and reported the allegation was accurate. Wellness Coordinator, Alberto Gonzalez, was interviewed and denied the allegation. He reported medical appointments are being scheduled along with transportation. Staff interviews revealed R1 frequently refuses to attend medical appointments that have been scheduled by staff. In addition, an interview with a witness reported R1 is no longer being seen by a previous primary care physician due to aggressive behavior. The LPA observed proof of scheduled appointments for R1 on file going back to June 2024. Therefore, based on interviews and record review, this allegation is deemed UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240826103259

FACILITY NAME:GROVE ASSISTED LIVING, THEFACILITY NUMBER:
331881323
ADMINISTRATOR:MORA, MICHELLEFACILITY TYPE:
740
ADDRESS:3401 LEMON STREETTELEPHONE:
(951) 686-8202
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY:66CENSUS: 66DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kip McMillan, Administrator in TrainingTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that residents are adequately fed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator in Training, Kip McMillan, and informed him of the purpose for the visit.

A report was received by the Department alleging the facility food has caused Resident One (R1) to become ill with gastro-intestinal concerns and the facility staff failed to provide a variety of food. The investigation included staff and resident interviews, a review of records, and collection of relevant documentation. Seven staff interviews were conducted; of the seven four reported no knowledge of residents becoming sick from the food served at the facility. All seven staff members reported the food appears sufficient for resident needs. Six (6) resident interviews were conducted; only one out of the six residents reported becoming ill due to the food served, though no gastro-intestinal symptoms were of issue. In addition, four of the six interviews reported a variety of food is served, while one reported they did not know if a variety of food was served. R1 was interviewed and reported they have gotten ill from the food served by the facility, which included symptoms of
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20240826103259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GROVE ASSISTED LIVING, THE
FACILITY NUMBER: 331881323
VISIT DATE: 08/28/2024
NARRATIVE
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vomiting and diarrhea. R1 and staff reported that when R1 was hospitalized on 06/06/2024 no diagnoses was determined. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was reviewed with Wellness Coordinator Gonzalez and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240826103259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GROVE ASSISTED LIVING, THE
FACILITY NUMBER: 331881323
VISIT DATE: 08/28/2024
NARRATIVE
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A second allegation was received by the Department alleging staff are not administering one of R1's medications required for a special health condition. R1 was interviewed and reported they were unsure if the staff were or were not administering to them the medications required for their special health condition. In addition, R1 was unsure if they even had a prescription for the medication(s). A medication list was obtained for R1 and, according to Wellness Coordinator Gonzalez, R1 is being administered one (1) medication for treatment of the resident's special health condition. The LPA observed the medication to be stored at the facility and according to a Medication Administrator Record (MAR) the medication is being administered. Therefore, based on observation and record review, this allegation is deemed UNFOUNDED.

A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

This report was reviewed with Wellness Coordinator Gonzalez and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4