374600103-12-8-2023-08-AS-DSEA-CYBVSA-20231208154115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600103
Report Date: 12/08/2023
Date Signed: 12/08/2023 05:48:44 PM

Document Has Been Signed on 12/08/2023 05:48 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	GROVEVIEW BOARD AND CARE		FACILITY NUMBER:	374600103
ADMINISTRATOR:	TERESITA PEDROSO		FACILITY TYPE:	740
ADDRESS:	2204 GROVEVIEW ROAD		TELEPHONE:	(619) 512-1262
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	6	CENSUS: 6	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Teresita Pedroso, Licensee		TIME COMPLETED:	03:50 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) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself, was granted entry into the facility, and met with Teresita Pedroso, licensee, to whom she disclosed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. During today’s inspection, there were a total of six (6) residents residing in the home. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected the rooms. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, and meetings. The facility’s internal temperature was within regulatory range. Refrigerators and freezers were operational and food was appropriately stored. Hot water temperature in bathroom used by residents measured at 113.3 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in a locked cabinet. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present and had been serviced within the past 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GROVEVIEW BOARD AND CARE	FACILITY NUMBER: 374600103
	VISIT DATE: 12/08/2023

NARRATIVE

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LPA reviewed staff and resident records/files. A review of resident records reflected that resident appraisals had not been updated within the past 12 months. LPA also interviewed staff and residents; interviews did not raise any licensing concerns. Licensee also had proof of current/active business liability insurance. Administrator’s certification was recently renewed.

A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D), and a Plan of Correction was jointly developed with the licensee. Licensee was also issued a technical advisory and technical violations.

An exit interview was conducted with Teresita Pedroso, to whom a copy of this report, the LIC 809-D, LIC 9102TVs, LIC 9102TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit. Licensee’s signature on this report acknowledges receipt of copies of the reports and rights.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 05:48 PM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GROVEVIEW BOARD AND CARE	FACILITY NUMBER: 374600103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's review of resident files, the licensee did not comply with the section cited above in 6 of 6 resident records which poses potential health and safety risks to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Licensee offered to complete, in conjunction with the residents, a reappraisal of each resident and to provide copies of the updated appraisals toCommunity Care Licensing by the POC due date of 12/18/2023.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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