331881323-1-27-2025-18-AS-SMAZ-DDC3X9-20250127173758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881323
Report Date: 01/27/2025
Date Signed: 01/27/2025 05:38:10 PM

Document Has Been Signed on 01/27/2025 05:38 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GROVE ASSISTED LIVING, THE		FACILITY NUMBER:	331881323
ADMINISTRATOR/ DIRECTOR:	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:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:	Braulio Gonzalez, Wellness Director		TIME VISIT/ INSPECTION COMPLETED:	05:45 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), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Administrator, Kip McMillan, and Wellness Director, Braulio Alberto Gonzalez. They were informed of the purpose for the visit. The inspection included the following: Infection Control Plan: The facility has an Infection Control Plan in place. According to Wellness Director Gonzalez, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Infection Control training was observed to be on file, completed in December 2024, and is ongoing. Residents are regularly observed for changes in physical, mental, emotional, and social functioning as observed in the facility's Stop and Watch Early Warning Tool. Operational Requirements: The facility does have a Plan of Operation available at the facility. Proof of liability insurance was available and had an expiration date of 01/01/2026. The Licensee (GOLDEN EAGLE SENIOR LIVING,INC.) is a current and active corporation. Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied Wellness Director, Gonzalez. The LPA observed the buildings alarm panel, located on the first floor, to show, "system normal". Two (2) carbon monoxide devices were inspected on two of three floors and were observed to be operable. The LPA inspected eight (8) resident bedrooms throughout the three (3) assisted living designated floors. The LPA observed some maintenance to be needed, though no immediate health and safety concerns were observed. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available. The toilet, handwashing, and bathing facilities were in working condition. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. There are no pools or other bodies of water located at the facility. According to Wellness Director, Gonzalez, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use. Staffing: Separate staffing is available to perform independent tasks for the operation of the facility. According to Wellness Director Gonzalez, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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: 01/27/2025

NARRATIVE

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Administrator, McMillan, is present at the facility during normal working hours and a manager is available who is responsible for the continued operation of the facility when he is temporarily absent. Personnel Records-Training: Three (3) staff members (S7, S8, and S9) present at the facility during the visit were observed to not have fingerprint clearances. A citation and civil penalties will be issued. Training on dementia care, postural supports, restricted health conditions, and hospice was observed on file. Proof of medication training was not available for one (1) staff member (S5). A citation will be issued. Training on resident personal rights and abuse reporting was observed on file. Resident Rights-Information: The facility has an internet accessible device available for resident use. The LPA did observe the complaint poster (PUB 475), non-discrimination notice, and Personal Rights signage to be posted throughout the facility. Planned Activities: The facility does have activities for residents in care, which include socialization, group discussion, crafts, games, other recreation activities, and outings. The facility does have a staff member who has full responsibility to organize, conduct, and evaluate planned activities. There is sufficient space for activities at the facility. Food Service: The LPA inspected the facility's kitchen and dinning areas. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Modified diets appear to be provided to residents in care as special diet needs were observed to be noted on an online database utilized by dinning staff. Incidental Medical and Dental: The facility is arranging, or assisting in the arrangement of medical and dental care for residents. Staff are assisting residents with the administration of medication. The medication carts (3) were inspected and observed to be organized, secured and labelled appropriately. Centrally stored medication and destruction records were observed on file. Resident Records/Incidental Reports: The facility does maintain a continuing record of any illnesses, injuries, or medical or dental care, when it impacts the resident's ability to function or the services needed. Resident records showed pre-admission appraisals, admission agreements, and medical assessments on file. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care (service plans) as needed. The facility currently has an approved hospice waiver for ten (10) residents. There are currently three (3) residents receiving hospice services. There is currently one (1) resident receiving home health services. Disaster Preparedness: The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies, and other required information. According to Wellness Director Gonzalez, the plan was reviewed within the last year. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills was observed on file; available records showed a

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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: 01/27/2025

NARRATIVE

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Fire and Earthquake Drill were completed on 11/05/24. Residents with Special Health Needs: Resident hospice record (1) was observed to have the required care plan on file. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed.

An exit interview was conducted with Wellness Director, Gonzalez, in which this report was reviewed and a copy was provided, along with instructions on appeal rights and other supplementary documentation. Wellness Director Gonzalez reported he had no questions.

NOTE: The LPA was off the premises from about 12:20 PM to about 12:50 PM.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/27/2025 05:38 PM - It Cannot Be Edited

Created By: Stephanie Martinez On 01/27/2025 at 05:02 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GROVE ASSISTED LIVING, THE	FACILITY NUMBER: 331881323
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(c)(1)(A)

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3] out of 3 staff members (S7, S8, S9) who did not obtain either a criminal record clearance or an exemption. This poses a health, safety and personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	All 3 staff members left the proprerty prior to the ending of the LPA's visit. Wellness Director Gonzalez reported neither staff member would return until a clearance was obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Stephanie Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/27/2025 05:38 PM - It Cannot Be Edited

Created By: Stephanie Martinez On 01/27/2025 at 05:05 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GROVE ASSISTED LIVING, THE	FACILITY NUMBER: 331881323
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(1)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 staff member who did not complete the above required training. According to Wellness Director, Gonzlez, S4 has been administering medication prior to the completion of the training. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Welnness Director Gonzalez reported a letter indicating S5 would not be administering medications when at the facility until the training is completed would be submitted to the Department by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Stephanie Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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