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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209327
Report Date: 05/28/2024
Date Signed: 05/28/2024 06:21:19 PM

Document Has Been Signed on 05/28/2024 06:21 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GROVE HOME LLC, THEFACILITY NUMBER:
547209327
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, EESAENGFACILITY TYPE:
735
ADDRESS:3413 E GROVE AVETELEPHONE:
(559) 786-1819
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator (Admin) Eesaeng MartinezTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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An Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Administrator (Admin) Eesaeng Martinez. LPA introduced self & was allowed to proceed with visit. Facility telephone number is (559) 623-9712.

Physical plant toured. Client front, dining, & living room sufficiently furnished with adequate lighting. Resident bedrooms toured. Resident bathrooms toured. Fixtures operational. Hot water measured @ 113 degrees F.

Laundry room toured. Hazardous chemicals &/or cleansers inaccessible. Garage toured. Outside area toured. East side yard observed to have rodent snap-trap set in walkway, next to step-up. Trap removed & made inaccessible @ time of visit. Shed on West side yard observed to have unlocked shed containing gas powered lawn mower & leaf blower. Shed locked @ time of visits making contents inaccessible to clients.

Medications observed to be locked. Centrally stored medication & destruction records reviewed. MARs reviewed. Medication documentation appeared to be in compliance. Interior & exterior passageways observed to be clear of obstructions. Fire extinguisher service date: 3/15/2024.

Deficiencies issued & cleared during this visit.

Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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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Document Has Been Signed on 05/28/2024 06:21 PM - It Cannot Be Edited


Created By: Kelly J. McClurg On 05/28/2024 at 05:15 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GROVE HOME LLC, THE
FACILITY NUMBER: 547209327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Rodent snap trap observed in walkway of East side yard. Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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Trap removed & made inaccessible @ time of visit.

DEFICIENCY CLEARED
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Gas powered lawn mower & leaf blower observed in unlocked storage shed on west side yard. Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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Storage shed locked @ time of visit making contents inaccessible to clients.

DEFICIENCY CLEARED
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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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