<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701143
Report Date: 07/08/2022
Date Signed: 08/30/2022 07:58:45 AM


Document Has Been Signed on 08/30/2022 07:58 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, 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: 4DATE:
07/08/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Manuel Sandoval, AdministratorTIME COMPLETED:
01:15 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
On 07/08/2022 at 9:30 AM, Licensing Program Analyst (LPA) R. Campbell and LPA M. Bilger conducted an unannounced post-licensing visit.. LPA R. Campbell met and toured with Administrator Manuel Sandova and Administrator Vilma Nunez. The administrator currently holds a certificate (#6049137740) that expires on 08/12/2022.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms of which 5 bedrooms are occupied by the residents and 2 staff members occupy 1 bedroom. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Bathroom #1 is used only for toileting for the residents and staff. Bathroom #2 is available for both toileting and showering for staff and residents. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Water temperature was measured at 105.2 degrees Fahrenheit.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on August 16, 2021. First aid kit was observed to be complete. The backyard was observed to have a fire exit without obstructions.

LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. All staff have current first aid training. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA R. Campbell reviewed 3 of 4 residents’ files and 4 of 4 staff files.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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 3


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: 07/08/2022
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
26
27
28
29
30
31
32
The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. The following deficiencies were found:

a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
87309(a)(1)

Exit interview was held, and a copy of this was report was given to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/30/2022 07:58 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2022
Section Cited

1
2
3
4
5
6
7
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

1
2
3
4
5
6
7

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3