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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701143
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:54:29 PM


Document Has Been Signed on 03/24/2022 04:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GROVE ST CARE HOME, LLCFACILITY NUMBER:
342701143
ADMINISTRATOR:SANDOVAL, MANUEL ALBERTOFACILITY TYPE:
740
ADDRESS:9189 GROVE ST.TELEPHONE:
(916) 686-2859
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Manuel SandovalTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Maja Jensen arrived unannounced to conduct a pre-licensing change of ownership. LPA Jensen was allowed access to the facility. LPA Jensen met with Manuel Sandoval and Jim Jones and explained the purpose of today's visit. Manuel Sandoval holds a current Administrators certificate # 6049137740 and teh certificate is good through 8/12/22.

LPA Jensen was screened at the door and had temperature taken as a COVID pre-caution. LPA observed sign in logs and hand sanitizer at the front entrance. All required signs were posted in prominent areas throughout the facility. The current census is 5 of which 2 are ambulatory and 3 are non-ambulatory. LPA Maja Jensen observed the dining room, living room, two bathrooms, kitchen, laundry room, grounds and garage. There are 6 bedrooms of which 5 are resident bedrooms and one is a staff bedroom. 4 out 5 resident bedrooms are private rooms. The posted facility sketch accurately reflects the facility rooms and room usage. The bedrooms are adequately furnished with a chair, night stand, dresser and lamp for each resident. The lighting throughout the facility is adequate and all rooms were sanitary and in good repair. The temperature in the facility was set at 74 degrees which is within the required range. LPA Jensen observed at least 2 days of perishable food and 7 days of non-perishable food.

Toxins and sharp objects were observed to be locked and inaccessible to residents. The first aid kit was observed to contain tweezers, scissors, antiseptic, bandages and a thermometer. The water temperature was measured in 2 of 2 bathrooms and measured at 112.4 and 108.9 which falls within the required range of 105 to 120 degrees. Resident and staff files were reviewed and observed to be complete. The disaster plan, plan of operation and admissions agreement was reviewed and observed to be complete. There are carbon monoxide and fire alarms present within the facility and in good working order. The grounds were observed to be well maintained and clear of debris or obstructions.

continued......
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GROVE ST CARE HOME, LLC
FACILITY NUMBER: 342701143
VISIT DATE: 03/24/2022
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The applicant has passed the pre-licensing component of the application process. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. A component III orientation presentation was completed with Licensee Manuel Sandoval.

An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2