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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006736
Report Date: 12/30/2025
Date Signed: 12/30/2025 02:25:54 PM

Document Has Been Signed on 12/30/2025 02:25 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GROVES OF TUSTIN, THEFACILITY NUMBER:
306006736
ADMINISTRATOR/
DIRECTOR:		CRUZ, WENDYFACILITY TYPE:
740
ADDRESS:1262 BRYAN AVENUETELEPHONE:
(714) 627-5947
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 100CENSUS: 68DATE:
12/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Susan Ruiz Hidalgo - Executive Director TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing inspection. LPA identified themselves and discussed the purpose of the visit with Executive Director Susan Ruiz Hidalgo an initial application to operate a Residential Care Facility for the Elderly application was received by CCL on 01/28/2025 for a capacity of 70 non-ambulatory and 30 bedridden residents for a total of 100 resident capacity.
LPA Mendivil along with Health and Wellness Director Robin Aquino, Executive Director Susan Ruiz Hildago and Memory Care Director Alma Gomez toured the facility at 10:00AM and observed the following:
Structure: Facility is a three story building with , 82 rooms, 6 public restrooms. The exit gates on first floor are secured delayed egress. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: First floor is Assisted Living with 25 single occupancy rooms all of which contain their own bathrooms. Second floor is a secured Memory Care with 26 rooms of which 10 rooms are shared occupancy. Third floor is Assisted Living with 31 rooms all of which are single occupancy. Bathrooms: Resident bathrooms have a working toilet/ wash basin .Linens & Hygiene Supplies: Facility supplies basic care items such as toilet paper and paper towels. Emergency Phone Numbers and Exit Plan: Posted behind receptionist desk in entry of facility. . Food Service: Licensee has 2 day perishable and 7-day nonperishable foods kept in facility kicthen. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested by Fire Service Corp on 10/20/2025. Appliances: Faciltiy kitchen's appliances such as oven, stove top and refrigeration were operational. Toxins/ Sharps: LPA observed a secure area for sharps in secured kitchen. CONTINUED ON LIC 809C DATED 12/30/2025.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GROVES OF TUSTIN, THE
FACILITY NUMBER: 306006736
VISIT DATE: 12/30/2025
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Water Temperature: LPA tested hot water and it read as following 106.7 to 110.3 degrees fahrenheit. Emergency Supplies: LPA observed supply of emergency water and food in staff break room and dry storage area in dining room. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication is stored in a secured medication cart which are housed in secured medication rooms on the first and second floors. Resident & Staff File: Resident records such as admission agreements and intake documents are stored in secured Executive Director's office and medical documents such physicians report and orders are stored in secured medication rooms. Reading Material, Games, and Equipment: . LPA observed games and coloring books in facility in facility palor. Backyard: LPA observed a shaded area for residents. Fire Clearance: Approved for 70 non-ambulatory and 30 bedridden residents on 09/08/2025.

Facility is ready to be licensed. Component III completed. Exit interview conducted and a copy of this report was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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