Groves of Tustin, the.

Per interviews with 5 out of 5 staff deny R1 was left in soiled diaper for an extended period of time. Based on interviews with staff stated they cue residents before and after breakfast, lunch and dinner and if resident's display signs of needing to use the restroom. Based on interviews with 7 out of 7 residents stated all of their needs are being met. Per interviews with 3 out of 5 staff that provide bathing assistance stated that R1 received 2 showers per week as stated in their care plan. Per review of end of shifts notes R1 showers were scheduled on Tuesday and Fridays and per review were given. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations that Staff allowed resident to be left in soiled clothing for extended periods of time and Staff did not provide resident with bathing assistance is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided. 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 Based on observations made on visits on 1/30/2025, 02/10/2025, 02/28/2025, 3/27/2025, 6/27/2025, 8/13/2025, 10/09/2025, 11/19/2025 and 12/30/2025 LPA Mendivil observed residents in both Assisted Living and Memory Care participating in various activities including bingo, music and an outing to the pumpkin patch. It was alleged that staff did not ensure R1 was seen for changes in a timely manner. Per review of care notes and end of shift notes dated 01/30/2025 the first documented issue was a rash listed for R1. Based on file review a Nurse Practitioner provided a prescription for a medicated powder on 02/01/2025. Per interviews with Memory Care Director Alma Gomez the family was notified of the rash when it was discovered. Therefore based on the preponderance of evidence through records reviewed and observations the allegations that Staff does not ensure a variety of planned activities are offered to residents in care and Staff did not ensure resident was seen for changes in health condition in a timely manner are determined to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided.

Interviews with 7 out of 7 residents stated their needs are met and staff is not neglectful. Based on interviews with residents they stated that the staff is very helpful and responsive. Interviews with Memory Care Director Alma Gomez stated if someone is a fall risk the facility will implement the following: review medications , check for UTI's or other health conditions, review of flooring and lighting and ensure there are zero tripping hazards. Alma stated they will also check resident's shoe wear to ensure they are non-slip and properly worn. Alma stated if a fall risk is due to gait then the facility will have resident in physical therapy to improve gait, if possible. Therefore based on the preponderance of evidence through interviews the allegation that resident Staff failed to supervise resident resulting in multiple falls and injuries is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.

Interviews with 7 out of 7 residents stated their needs are met and staff is not neglectful. Based on interviews with residents they stated that the staff is very helpful and responsive. Therefore based on the preponderance of evidence through interviews the allegation that resident was neglected and lacked proper care and supervision, is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.

Per review of Unusual Incident/Injury Report for 09/24/2021 it was reported R1 was found on the floor by staff and was assessed, R1 did not complain of pain and was able to ambulate with walker. Per report both R1's physician and responsible party were notified. It was also reported that resident was placed on alert charting and service plan was updated. Per review of Unusual Incident/Injury Report for 11/18/2021 it was reported R1 was found in the bathroom floor after R1 attempted to use the restroom. Per report R1 hit her head and 911 was called and R1 was assessed by paramedics but refused transfer to the hospital. Per report paramedics did not note any bumps on R1's head. R1 was placed on alert charting and mention of physical therapy and occupational therapy to continue to work with R1. R1's family and physician were notified and service plan was updated. Per review of Unusual Incident/Injury Report for 04/18/22 it was reported R1 reported to staff that they had chest pains and R1 was sent out to the hospital. R1's family and physician were notified. R1 was admitted to the hospital until 04/21/2022 diagnosis was pneumonia, R1 was notified needed a stent replacement but declined surgery. Per review of Unusual Incident/Injury Report for 04/21/2022 it was report R1 was found on the floor next to their bed by staff. R1 was noticed to have blood and bruised left eye and hand. 911 was called and R1's family and physician were notified. R1 was admitted to the hospital and returned to the community on 04/22/2022. Per report a 1:1 caregiver was put in place following hospital discharge. Per Progress notes dated on 05/25/2022 it was reported R1's 1:1 caregiver notified staff that R1 had fallen and staff went to assess resident, during assessment R1 had purple lips, 911 was called. It was reported that staff notified R1's family and physician. R1 was admitted to the hospital until 05/28/2022. R1 was admitted to hospice on 06/09/2022. Per review of Unusual Incident/Injury Report for 07/17/2022 during rounds staff went to open R1's door but could not due to R1 blocking the door. Per report staff was able to access the resident's room via patio door. 911 was called and resident was taken to the hospital. R1's family and physician was notified. 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 R1 was discharged on 07/18/2022 and was placed on alert charting and admitted back into hospice. Per review of Unusual Incident/Injury Report for 07/19/2022 it was reported that R1's room door was noted to be opened around 04:10am by staff and then around 4:55am the door was closed and staff entered the room and saw R1 on the floor. R1 was bleeding from their head 911 was called. R1's family and physician were notified. R1 was admitted to the hospital and did not return to the facility after discharge. Per review of R1's service plan R1 was identified as a fall risk with mitigation such as clutter free pathways, staff assist to walk to and from to events, call pendant, and increased monitoring overnight for bathroom assist. Per review of progress notes dated 07/05/2022 R1's family discontinued 1:1 caregiver. Interviews with staff and witness stated R1 would get up on their own and ambulate and not call for assistance. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that Resident sustained injury due to neglect is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management. LPA was greeted and granted entry into the facility and explained the reason for the visit. LPA Mendivil received a call from Executive Director (ED) Wendy Cruz on 09/22/2025 regarding an incident that occurred on 09/21/2025 around 8pm. ED stated around 8pm two staff members in Memory Care saw an intruder while they were conducting rounds. ED stated all exterior doors were locked on the first floor as it was after visiting hours. ED stated the Tusti PD believe the intruder entered from a second story door or window as Memory Care does not have direct access without a code. Staff called 911 and called Resident Care Director who was on the first floor. Per ED Tustin PD arrived shortly after and apprehended the intruder. Per ED no residents were harmed and staff conducted visual checks on all residents in Memory Care. LPA Mendivil did not observe any health and safety concerns. Based on the observations made during today's visit, no violations noted. Exit interview conducted and a copy of this report was provided.

It is alleged that the facility did not administer medication as prescribed on or around 07/29/2025 for R1. Per interviews with Memory Care Director Alma Gomez, R1 had complained of pain of her hands to med tech staff. Alma stated then med-tech staff reported the issue to R1's primary care physician (PCP) office who then told med tech staff that they were going to send a prescription over to the pharmacy. It was then reported on 07/31/2025 Med-tech staff called PCP's office to follow up on the prescription and was told by PCP's office that they will send it over on 07/31/2025. Alma stated the facility received the medication from the pharmacy on 07/31/2025 in the PM and it was administered per physician's orders on 08/01/2025. It was alleged that the facility staff did not allow resident to participate in activities. Based interview with Alma stated she has never denied a memory care resident participation in a memory care outing. Alma stated that assisted living and memory care have their own outings as their care levels are different. Alma stated there are only 8 seats on the bus and availability is limited so the activity staff tries to rotate residents that want to participate. During the visit LPA Mendivil observed memory care residents on the first floor waiting for the bus to take them on their outing. It was alleged the facility violated residents rights. Based on interviews with 6 out of 6 staff stated they do not violate residents rights including: forcing a resident to wake up earlier than wanted or to participate in activities they do not wish to. LPA Mendivil interviewed 2 memory care residents that stated no one has violated their rights. Therefore based on the preponderance of evidence through records reviewed, observations and interviews the allegations Medication not administered as prescribed, Facility staff did not allow resident to participate in activities and Facility violated resident's rights are determined to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided. 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 Per review of LIC 621 Client/Resident Personal Property and Valuables for R1 has one item logged as " wedding ring". Per interviews with Memory Care Director Alma Gomez stated that around 07/02/2025 after marquee ring was reported missing the memory care staff checked R1's room and were unable to locate the ring. Based on interview with Alma and Executive Director Wendy Cruz they inspected R1's on 08/06/2025 to search for the pearl ring which they could not locate. Alma stated asked R1's family to provide information regarding the missing rings and missing tops, and was provided that information on 08/08/2025 via email. On 08/11/2025 Alma along with Staff 1 (S1) went into R1's room and were able to locate all but two tops. Per interviews with Alma the facility has conducted an investigation which resulted in no findings. Per Alma the Tustin PD was notified and reached out to her on 08/06/2025 inquiring about the missing items, per Alma no case number was provided. Interviews with 5 out of 5 staff stated they did not take any items from R1. Interviews with 2 out of 3 residents stated they have not had items taken, the final resident was not oriented to time and space and could not answer LPA's questions. Therefore based on the preponderance of evidence through records reviewed the allegation that Facility did not safeguard resident's property is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by Alma Gomez, Memory Care Director and explained the reason for the visit. The facility is a three- story building with an approved fire clearance of 100 non-ambulatory residents of which 30 may be bedridden. The facility currently has a census of 71 residents in care. LPA reviewed 4 staff records and reviewed 6 resident records. All files contained the required documentation . LPA confirmed that administrator has a current administrator certificate which expires on 11/14/2025. LPA Mendivil toured the facility with Memory Care Director Alma Gomez and Maintenance Director German Favila Sosa. LPA toured the facility and inspected the physical plant and tested hot water temperature in common bathrooms. The hot water temperature measured between 105 and 109 degrees F and all smoke detectors were operational and last maintenance on 12/19/2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review completed medication appear to be being given as prescribed. No deficiencies noted on today's visit. An exit interview was conducted and a copy of this report was provided.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management. LPA was greeted and granted entry by Alma Gomez and explained the reason for the visit. On 02/28/2025 the Department received a Death Report (LIC 624A) for Resident 1 (R1). It was reported by the facilty that R1 was found deceased in their room by staff on 2/26/2025. Memory Care Director Alma Gomez called 911 and Tustin Police Department and paramedics arrived. Alma stated paramedics determined that R1 was deceased and Orange County Corners office arrived around 12:30pm and R1 was taken to the Corner's office. LPA Mendivil obtained copies of preplacement appraisal, advance directive and Physician's Orders for Life Sustaining Treatment (POLST). LPA Mendivil toured the facility and residents were in the dining room for dinner. No health or safety violations noted during today's visit. Based on the observations made during today's visit, no violations noted. Exit interview conducted and a copy of this report was provided.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry into facility Debbie Garibaldi, Resident Care Director and explained the reason for the visit. The Department received an Unusual Incident/Injury Report LIC 624 for Resident 1 (R1) it was reported that on 01/20/2025 complained of pain to Staff 1 (S1). S1 then called Debbie, Resident Care Director. Debbie checked on R1 and called non emergent ambulance. R1 was taken to the hospital and responsible party was notified. R1 received a CAT scan and was diagnosed with a fracture. R1 was then taken back to the facility with new medication orders. R1 then had a follow up with orthopedics 01/24/2025 and they are currently waiting authorization for MRI. R1 is currently back at the facility and appears well groomed. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.

Licensing Program Analysts (LPAs) Michael Tea and Rose Ruppert with Licensing Program Manager (LPM) Alisa Ortiz made an unannounced visit to the facility today to conduct a Case Management Plan of Correction (POC). LPAs and LPM were greeted and granted entry by Alma Gomez, Memory Care Director . During today's visit LPAs and LPM met with Liana Foote, Executive Director. The purpose of today's visit was to follow-up in regards to deficiency cited during an annual required visit conducted on March 27, 2024. During inspection the facility was cited California Code of Regulations Title 22 Section 87355(e)(1) . The POC was due on March 28, 2024. On this day LPA verified POC was corrected. Deficiency cleared. An exit interview was conducted and a copy of this report was given to the facility.