The Grove Assisted Living

Allegation investigated: Staff does not ensure that resident is adequately fed while in care. Staff does not meet resident's grooming needs.

On April 28, 2026, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Alberto Gonzalez and reason for visit explained Investigation consisted of the following: On December 6, 2023, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, it was determined that the complaint required further investigation. On April 28, 2026, the Department obtained copies of the following documents: Staff oster dated 4/15/26), Resident Roster (dated: 4/22/26), R1’s medical reports (dated: 9/8/23) R1’s pre-appraisal (dated: 9/9/23) R1’s Needed and services plan (dated: 9/9/23), Dietary Request form (dated: 9/8/23), Shower Scheduled, Medication Orders 9/8/23 Physician orders (9/8/23), and Menu (March 2026) The department interviewed Administrator (A1) 4 staff (S1-S4), 6 Residents (R2-R7). R1 no longer lives at the facility as of 3/1/23). Page 1 of 4 Unsubstantiated The investigation revealed the following: Allegation: Staff does not ensure that resident is adequately fed while in care. The detail of the complaint alleges R1 is only given a small portion of food and doesn't appear to be eating well. On April 28, 2026, the department interviewed Wellness Coordinator (A1) who denied the allegation stating that there has been no report of R1 not getting enough food here. A1 further stated that R1 was a “good eater” that he was given snacks or extra food when he requested it. Lastly, A1 stated that residents could ask for "seconds" of meals if they wanted and his staff would provide it. On April 28,2026 between 12:30pm and 1:30pm the department interviewed 4 staff (S1-S4) regarding the allegation and 4 out of 4 denied the allegation stating that residents are adequately fed at the facility. 4 out of 4 stated that if residents ask for extra food or snacks they are available to them. Lastly, when asked what happens if a resident refuses food, 4 out 4 staff interviewed stated that they have an alternative meal option for the residents. Lastly, 1 of the 4 staff interviewed informed the department that she follows a recommended portion spread sheet that is from a Registered Dietician however, it can be adjusted based on the preference and need of the resident. On April 28, 2026 the department interviewed 6 residents (R2-R7) regarding the allegation 6 out of 6 denied the allegation stating that get enough to eat and if they wanted “seconds” they are given "seconds." When asked if they have access to snacks, 6 out of 6 stated that they are offered snacks. Lastly, 6 out of 6 residents interviewed stated that they are well taken care of and the staff assist them when needed. Page 2 of 4 On April 28, 2026, the department obtained, reviewed and evaluated the following documents: Resident Roster (dated: 4/22/26), R1’s medical reports (dated: 9/8/23) R1’s pre-appraisal (dated: 9/9/23) R1’s Needed and services plan (dated: 9/9/23), Dietary Request form (dated: 9/8/23), Medication Orders 9/8/23 Physician orders (9/8/23), and Menu (March 2026) On April 28, 2026 during tour of the facility, department observed meal service and noted the portion sizes were adequate and well balanced. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff does not meet resident's grooming needs. The detail of the allegation alleges that on 11/25/23 R1 was observed as not well groomed On April 28, 2026, the Department interviewed Wellness Coordinator (A1) who denied the allegation and stated that there were no reports of R1 not being well groomed. A1 further stated that he observed R1 daily and there were no issues in that area. A1 stated that he would have addressed it that was an issue. Page 3 of 4 On April 28, 2026, the department interviewed 4 staff regarding the allegation. Of those interviewed 4 out of 4 denied the allegation citing that they follow a shower schedule for the residents and that all residents are properly groomed. On April 28, 2026 the department interviewed 6 residents and of those interviewed 6 out of 6 state they are well care for and their grooming and hygiene needs are met. On April 28, 2026, the department observed that the residents were adequately dressed and properly groomed. On April 28, 2026, the department obtained and reviewed a copy of the facility shower schedule and found it to be consistent. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 4 of 4the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 18-AS-20231129150528

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Seo Jeon and Ahliah Sharp conducted an unannounced annual required visit. LPA met with Baylor Romney, executive director, and informed them of the purpose of the visit. At the time of the visit, there were six (6) staff members and 63 residents present. Alberto Gonzalez, Resident Wellness Director, joined later during the inspection. Facility Overview: The facility is a seven story building with 66 bedrooms and 66 bathrooms. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA obtained and reviewed annual fire safety inspection report dated 10-09-2025. LPA confirmed that the facility passed the fire safety inspection. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. ***Continued on LIC809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in a medication room located on the third floor. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 12-07-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Staff did not prevent resident from getting financially abused

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. The LPA met with Baylor Romney, Operations Manager, and informed them of the purpose of the LPA’s visit. The LPA conducted a tour of the interior and exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. LPA interviewed residents and staff. LPA did not observe any health and safety concerns. On 11-18-2025, Community Care Licensing (The Department) received a complaint report alleging that staff did not prevent resident from getting financially abused. LPA's record review revealed the Resident #1 (R1) is a resident at independent living section of the facility. LPA's record review also revealed the Suspected Abuser (SA) is not a staff member of the facility. LPA determined that the Department does not have regulation over the independent side of the facility where R1 is residing. Continued on LIC9099-C.... Unfounded Based on information obtained from interviews, and record reviews, the allegation that staff did not prevent resident from getting financially abused is UNFOUNDED. A finding of UNFOUNDED means the allegation could not have happened, is false, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 18-AS-20251118103916

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding an eviction notice received by the Department on September 12, 2025. LPA spoke with Kip McMillan, Administrator, and Alberto Gonzalez, Resident Wellness Director, and informed them the purpose of the LPA's visit. LPA conducted a tour of the interior and exterior of the facility. LPA did not find any health and safety concern for the residents in care at the time of the visit. LPA obtained documents for Resident #1 (R1). They are LIC602, contract agreement among R1, The Grove Assisted Living, and the Assisted Living Waiver Program, Care Plan, and Riverside Police Department report number. LPA also obtained Resident #2's (R2) credit card transaction detail. R1's appraisal will be sent by 09-16-2025 via email. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided.the state’s words, verbatim · CDSS document, Sep 15, 2025

Allegation investigated: Staff are not safeguarding residents personal belongings. Staff are financially abusing residents.

Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced visit to the facility to initiate the investigation into the allegations listed above. LPA met with Office Manager Angelica Talavera and was informed of the purpose of the visit. During the visit, LPA toured the facility and conducted two (2) staff interviews. LPA requested resident records, resident roster, and staff roster for review. Information obtained from records reviewed revealed Resident # 1 (R1) is not a resident at the facility. LPA conducted an interview with office manager Angelica Talavera who reported R1 has never resided at the facility, R1 was admitted to the Skilled Nursing Facility on 01/23/23 and was discharged on 03/29/24. LPA conducted an interview with staff #1 (S1) and reported that R1 has never resided at the Assisted Living facility. Unfounded This agency has investigated the complaints alleging staff are not safeguarding residents personal belongings and staff are financially abusing residents. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 18-AS-20250729095703

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection at the facility. The LPA was allowed entrance into the facility and met with Administrator, Kip McMillan, and Wellness Director, Braulio Alberto Gonzalez. They were informed of the purpose for the visit. The inspection included the following: Infection Control Plan: The facility has an Infection Control Plan in place. According to Wellness Director Gonzalez, the facility is following the policies listed in the plan whenever there are infectious outbreaks within the facility. Infection Control training was observed to be on file, completed in December 2024, and is ongoing. Residents are regularly observed for changes in physical, mental, emotional, and social functioning as observed in the facility's Stop and Watch Early Warning Tool. Operational Requirements: The facility does have a Plan of Operation available at the facility. Proof of liability insurance was available and had an expiration date of 01/01/2026. The Licensee (GOLDEN EAGLE SENIOR LIVING,INC.) is a current and active corporation. Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied Wellness Director, Gonzalez. The LPA observed the buildings alarm panel, located on the first floor, to show, "system normal". Two (2) carbon monoxide devices were inspected on two of three floors and were observed to be operable. The LPA inspected eight (8) resident bedrooms throughout the three (3) assisted living designated floors. The LPA observed some maintenance to be needed, though no immediate health and safety concerns were observed. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available. The toilet, handwashing, and bathing facilities were in working condition. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. There are no pools or other bodies of water located at the facility. According to Wellness Director, Gonzalez, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use. Staffing: Separate staffing is available to perform independent tasks for the operation of the facility. According to Wellness Director Gonzalez, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members. Administrator, McMillan, is present at the facility during normal working hours and a manager is available who is responsible for the continued operation of the facility when he is temporarily absent. Personnel Records-Training: Three (3) staff members (S7, S8, and S9) present at the facility during the visit were observed to not have fingerprint clearances. A citation and civil penalties will be issued. Training on dementia care, postural supports, restricted health conditions, and hospice was observed on file. Proof of medication training was not available for one (1) staff member (S5). A citation will be issued. Training on resident personal rights and abuse reporting was observed on file. Resident Rights-Information: The facility has an internet accessible device available for resident use. The LPA did observe the complaint poster (PUB 475), non-discrimination notice, and Personal Rights signage to be posted throughout the facility. Planned Activities: The facility does have activities for residents in care, which include socialization, group discussion, crafts, games, other recreation activities, and outings. The facility does have a staff member who has full responsibility to organize, conduct, and evaluate planned activities. There is sufficient space for activities at the facility. Food Service: The LPA inspected the facility's kitchen and dinning areas. The LPA observed all food to be of good quality. All readily perishable foods and beverages capable of supporting rapid and progressive growth of micro-organisms were stored in covered containers at appropriate temperatures. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects. Modified diets appear to be provided to residents in care as special diet needs were observed to be noted on an online database utilized by dinning staff. Incidental Medical and Dental: The facility is arranging, or assisting in the arrangement of medical and dental care for residents. Staff are assisting residents with the administration of medication. The medication carts (3) were inspected and observed to be organized, secured and labelled appropriately. Centrally stored medication and destruction records were observed on file. Resident Records/Incidental Reports: The facility does maintain a continuing record of any illnesses, injuries, or medical or dental care, when it impacts the resident's ability to function or the services needed. Resident records showed pre-admission appraisals, admission agreements, and medical assessments on file. The facility does conduct re-appraisals on residents, and updates are made to resident's written record of care (service plans) as needed. The facility currently has an approved hospice waiver for ten (10) residents. There are currently three (3) residents receiving hospice services. There is currently one (1) resident receiving home health services. Disaster Preparedness: The facility does have an emergency and disaster plan in place, which included contact information for appropriate agencies, and other required information. According to Wellness Director Gonzalez, the plan was reviewed within the last year. Proof of staff training on emergency procedures was observed on file. Proof of emergency drills was observed on file; available records showed a Fire and Earthquake Drill were completed on 11/05/24. Residents with Special Health Needs: Resident hospice record (1) was observed to have the required care plan on file. No smoking - Oxygen in use, signs were observed to be posted throughout the facility. Staff training in oxygen administration was observed to be completed. An exit interview was conducted with Wellness Director, Gonzalez, in which this report was reviewed and a copy was provided, along with instructions on appeal rights and other supplementary documentation. Wellness Director Gonzalez reported he had no questions. NOTE: The LPA was off the premises from about 12:20 PM to about 12:50 PM.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Staff do not provide services as agreed in the resident's Admission Agreement Staff are not administering resident's medication

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator in Training, Kip McMillan, and informed him of the purpose for the visit. A report was received alleging facility staff have failed to assist Resident One (R1) with setting up and being transported to their medical appointments. The investigation included staff and resident interviews, a review of records and collection of relevant documentation. R1 was interviewed and reported the allegation was accurate. Wellness Coordinator, Alberto Gonzalez, was interviewed and denied the allegation. He reported medical appointments are being scheduled along with transportation. Staff interviews revealed R1 frequently refuses to attend medical appointments that have been scheduled by staff. In addition, an interview with a witness reported R1 is no longer being seen by a previous primary care physician due to aggressive behavior. The LPA observed proof of scheduled appointments for R1 on file going back to June 2024. Therefore, based on interviews and record review, this allegation is deemed UNFOUNDED. Unfounded vomiting and diarrhea. R1 and staff reported that when R1 was hospitalized on 06/06/2024 no diagnoses was determined. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with Wellness Coordinator Gonzalez and a copy was provided. A second allegation was received by the Department alleging staff are not administering one of R1's medications required for a special health condition. R1 was interviewed and reported they were unsure if the staff were or were not administering to them the medications required for their special health condition. In addition, R1 was unsure if they even had a prescription for the medication(s). A medication list was obtained for R1 and, according to Wellness Coordinator Gonzalez, R1 is being administered one (1) medication for treatment of the resident's special health condition. The LPA observed the medication to be stored at the facility and according to a Medication Administrator Record (MAR) the medication is being administered. Therefore, based on observation and record review, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. This report was reviewed with Wellness Coordinator Gonzalez and a copy was provided.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 18-AS-20240826103259

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Wellness Coordinator, Alberto Gonzalez and Administrator, Michelle Mora who were informed of the purpose of the visit. The facility is a (7) story building with floors: (3), (4), and (5) designated for assisted living, floor (1) contains staff offices and activity rooms. All other floors are not licensed with the department and contain independent and skilled nursing residents. The facility does not have a pool or fire arms, and has an outdoor activity space on the first floor. LPA observed the following: Infection Control: LPA observed hand hygiene supplies and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file and staff training plan that was reviewed during the visit. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and had ample space for resident activities. Laundry equipment was observed to be in good working condition. The carbon monoxide detector was tested and operational during the visit. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items, and provisions for modified diets. Record Review and Resident/Staff Files: LPA reviewed staff files and training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a medication room. LPA reviewed client medications and found that MARS and medication was accounted for and had required labeling. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 12/2/2023. LPA observed emergency exits were cleared, and observed evacuation chair. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to Wellness Coordinator, Alberto Gonzalez.the state’s words, verbatim · CDSS document, Jan 29, 2024