331881323-1-29-2024-18-AS-JARA-CZXR6E-20240129114438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881323
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:45:22 AM

Document Has Been Signed on 01/29/2024 11:45 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GROVE ASSISTED LIVING, THE		FACILITY NUMBER:	331881323
ADMINISTRATOR:	MORA, MICHELLE		FACILITY TYPE:	740
ADDRESS:	3401 LEMON STREET		TELEPHONE:	(951) 686-8202
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92501
CAPACITY:	66	CENSUS: 63	DATE:	01/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Wellness Coordinator, Alberto Gonzalez		TIME COMPLETED:	12:00 PM

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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Wellness Coordinator, Alberto Gonzalez and Administrator, Michelle Mora who were informed of the purpose of the visit. The facility is a (7) story building with floors: (3), (4), and (5) designated for assisted living, floor (1) contains staff offices and activity rooms. All other floors are not licensed with the department and contain independent and skilled nursing residents. The facility does not have a pool or fire arms, and has an outdoor activity space on the first floor. LPA observed the following: Infection Control: LPA observed hand hygiene supplies and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file and staff training plan that was reviewed during the visit. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and had ample space for resident activities. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items, and provisions for modified diets. Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/29/2024

NARRATIVE

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Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 12/2/2023. LPA observed emergency exits were cleared, and observed evacuation chair.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to Wellness Coordinator, Alberto Gonzalez.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

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