The Grove

Type of visit: Required - 1 Year

On 05/06/26, Licensing Program Analysts (LPAs) M. Vega arrived to the facility unannounced to conduct the required annual inspection, LPAs were greeted by Administrator - Norshell Brewer, stated the purpose of the visit and were allowed entry into the facility. LPAs toured the facility inside and out with Administrator. LPAs observed the facility to be 2 stories with 63 rooms in Assisted Living and 13 rooms in the Memory Care unit named “Journey”. Memory Care unit was observed to have a 15 second delayed egress system with a keypad and alarm. LPAs observed a hydro therapeutic tub located on the first floor in journey room and another on the second floor. Room 137 (1st floor) restroom water temperature reading was 115.3 degrees F and room 219 (2nd floor) restroom water temperature reading was 114.0 degrees F. Bedrooms were observed to have the required lighting and furnishings and were free from odor and any passageway obstruction / fire hazards. Facility temperatures throughout the facility were observed to be comfortable. Cleaning supplies were observed to be locked in janitorial closet located next to laundry room. LPA toured the kitchen observed the required 7-day supply of Non-perishable food and 2- day supply of fresh perishables to be properly stored. Menus for the facility were observed. LPA toured the kitchen and dining area which was being cleaned and prepped for dinner. LPAs observed a daily special and weekly menus posted at the entrance of the dining area. Facility has an Executive chef and a e-menu system that tracks daily meals and special diets for each resident in care. Continued on LIC 809C Medications were observed to be locked in Med carts located in a Wellness room and thought the areas of the facility. A sample medication audit was completed. LPA observed two Med technicians conduct a medication distribution as well. Facility has an Emergency Disaster plan and the Infection control plan on file. Emergency Disaster and Fire Drill logs were observed. Carbon monoxide detectors were observed throughout the facility and an annual inspection is conducted of those systems and sprinkler system as well. Fire Extinguishers throughout the facility were observed with a service date of 10/06/2025. A sample of Resident were reviewed and observed to have the required documentation and forms. Needs and service plans and physician’s reports were current. Home Health and Hospice care plans were also observed in resident files with physician orders. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator at the time of visit. No deficiencies cited on today's visit. Signature confirms receipt of this report.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Staff did not comply with reporting requirements. Staff did not provide requested record(s) to resident’s representative in a timely manner.

On 03/27/2026 Licensing Program Analyst (LPA) M Vega conducted an unannounced complaint investigation visit for the purpose of delivering the finding for the above allegations. LPA met with Executive Director - Norshell Brewer. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegations: Staff did not comply with reporting requirements and Staff did not provide requested record(s) to resident’s representative in a timely manner are found to be UNFOUNDED. Staff respond appropriately to incident involving resident. Report was filed and Due to memory/dementia issues it is unpredictable when resident’s may act out, but it is not due to lack of supervision. Based on the investigation it has been determined the allegations are UNFOUNDED meaning that the allegations were false, could not have happened or are without a reasonable basis. The complaint has therefore been dismissed. An exit interview was conducted a copy of the amended report provided to the Business Office Director - Nancy Braxton-Cartier Unfoundedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 24-AS-20260205114020

Allegation investigated: Staff did not seek timely medical attention for a resident

On March 27, 2026, Licensing Program Analyst (LPA) M Vega conducted an unannounced inspection at the facility and met with Executive Director - Norshell Brewer. The purpose of the visit was to open a complaint investigation and deliver findings regarding the above allegation. It was alleged that the facility, "Staff did not seek timely medical attention for a resident." Based on record review staff was immediately searching for resident 1 (R1), it has been determined that the facility does ensure R1 received medical care and determined the allegation is unfounded. This agency has investigated the complaint alleging “Staff did not seek timely medical attention for a resident” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis. We have found that the complaint was unfounded, therefore we have dismissed the complaint. An exit interview was conducted a copy of the amended report provided to the Business Office Director - Nancy Braxton-Cartier Unfoundedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 24-AS-20260128115035

Type of visit: Case Management - Incident

On 12/23/25 Licensing Program Analyst (LPA), M Vega to conduct an unannounced case management visit. LPA met with Business Office Director - Nancy Braxton-Cartier and arrived sometime later. This case management visit is being conducted for an Death Report (DR) dated 10/30/2025, regarding Resident 1(R1) Need clarification on Death Report LPA will request the following: (R1: Death Certificate, Corrected death report). At this time this case management does not need further review. Business Office Director was informed that additional documentation maybe needed. No deficiencies cited during todays visit. Exit interview completed with Business Office Director - Nancy Braxton-Cartier. A copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Dec 23, 2025

Allegation investigated: Staff do not ensure medications are dispensed as prescribed Staff due not ensure reporting requirements are being followed

On 05/22/2025, Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct a complaint investigation. LPA introduced self, stated the purpose of the visit to Administrator - Norshell Brewer. During the investigation, LPA conducted interviews and records reviews. Based on the information received, the allegations, Staff do not ensure medications are dispensed as prescribed and Staff do not ensure reporting requirements are being followed are Unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was discussed and provided to Administrator - Norshell Brewer whose signature on this form confirms receipt of this document. No citations were issued at the time of this visit. Unfoundedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 24-AS-20250312082833

Type of visit: Required - 1 Year

On 05/22/25, Licensing Program Analysts (LPAs) M. Vega and L. Salazar arrived to the facility unannounced to conduct the required annual inspection, LPAs were greeted by Administrator, stated the purpose of the visit and were allowed entry into the facility. LPAs toured the facility inside and out with Administrator. LPAs observed the facility to be 2 stories with 63 rooms in Assisted Living and 13 rooms in the Memory Care unit named “Journey”. Memory Care unit was observed to have a 15 second delayed egress system with a keypad. LPAs observed a hydro therapeutic tub located on the first floor. Bedrooms were observed to have the required lighting and furnishings and were free from odor and any passageway obstruction / fire hazards. Facility temperatures throughout the were observed to be in the low to mid 70’s. Cleaning supplies were observed to be locked in a janitorial closet located next to laundry room. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Menus for the facility were observed. LPA toured the kitchen and dining area where residents were having lunch. LPAs observed a daily special and weekly menus to posted at the entrance of the dining area. Facility has an Executive chef and a e-menu system that tracks daily meals and special diets for each resident in care. Continued on LIC 809C Carbon monoxide detectors were observed throughout the facility. Fire Extinguishers throughout the facility were observed with a service date of 04/04/25. First aid kits were observed to contain all required items. Medications were observed to be locked in Med cart located in a Wellness room. A sample medication audit was completed. Facility has an Emergency Disaster plan on file. Emergency Disaster and Fire Drill logs were observed. A sample of Resident were reviewed and observed to have the required documentation and forms. Needs and service plans and physician’s reports were current. Home Health and Hospice care plans were also observed in resident files with physician’s orders. LPA is requesting the following documents be submitted to the Fresno CCL office by 05/30/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC 308), Administrator Organization (LIC 309), Certificate of Liability Insurance Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020A). An exit interview was conducted with Administrator. A copy of this report was discussed and provided at the time of visit. No deficiencies cited on today's visit.the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Staff mismanaged resident's medication. Staff did not administer resident's medication as prescribed.

This is an amended report. On 09/24/2024, Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator Norshell Brewer, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegations. Allegation: Staff mismanaged resident’s medication. On 05/16/2024, during complaint investigation department reviewed facility records, interviewed staff and Administrator, and observed medications storage and dispensing for R1 and R2 accordingly. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated This is an amended report. Allegation: Staff did not administer resident's medication as prescribed. During complaint investigation department reviewed facility records, interviewed staff and Administrator, and observed the staff and residents during medication administration. Records review and interviews revealed that in July, 2024 medications were administered to residents as prescribed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted, report signed and copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 24-AS-20240514083051

Allegation investigated: Staff did not meet a resident's hygiene need while in care Staff did not provide a copy of the admission agreement to authorized representative Staff are not abiding to admission agreement

On 08/07/24, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Norshell Brewer and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD. Allegation: Staff did not meet a resident's hygiene need while in care. Based on file review residents that require assistance with hygiene services documented in daily care notes. Per staff interview and records review, residents unable to provide selfcare, where assisted at different times. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Report continues on attached LIC9909-C Unsubstantiated Staff did not provide a copy of the admission agreement to authorized representative. Based on records review and staff interview copy of admission agreement was provided initially to authorized representative on 12/27/23 and on 3/21/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Staff are not abiding to admission agreement. Based on records review, staff and residents interview no concerns from observed from residents interviewed. During facility visit on 03/25/2024 no deficiencies were observed in regard to Admission Agreement violation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. No deficiencies were observed during this visit. Exit interview conducted, report signed and copy of this report provide to Administrator for facility records.the state’s words, verbatim · CDSS document, Aug 7, 2024 · control 24-AS-20240321112201

Type of visit: Required - 1 Year

On 05/28/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) Norshell Brewer, certification number 6030647740 and expiration date 07/16/2024. LPA conducted tour inside and out of facility with ED. Residents were observed at the facility during breakfast and in common areas. The facility was observed to be at a comfortable temperature of 74 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 10/18/2023 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week on Mondays and Wednesdays. Refrigerator temperature was maintained at 43.0-degree F. and freezer was maintained at -6-degree F. LPA toured a sample of resident bedrooms. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 106 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on LIC809-C Samples of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan and medication records. Also staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 06/04/2024 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the ED. A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, May 28, 2024