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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606329
Report Date: 10/19/2022
Date Signed: 10/19/2022 11:44:43 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20221012112740
FACILITY NAME:PARK PLACE RESIDENTIAL CAREFACILITY NUMBER:
197606329
ADMINISTRATOR:MARIA ALVIRFACILITY TYPE:
735
ADDRESS:10401 DENSMORE AVENUETELEPHONE:
(818) 920-1084
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Alvir/ AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility administrator. The facility conducted all COVID-19 protocols before allowing the LPA into the facility. The LPA explained the reason for the visit.
Allegation 1. Resident sustained unexplained injury while in care.
The LPA was able to speak with staff, the administrator, the resident in question (R1) and review facility documentation in order to come to a finding. Interviews conducted with facility staff revealed that R1 was placed to bed on 10/7/22. On the morning of 10/8/22, R1 woke up with a bruise under the right eye. Staff interviewed denied that there was any type of accident, nor did they ever receive complaints of pain from R1. R1 was interviewed and did not know how R1 received the bruise. R1 was observed to be verbal and aware of R1's surroundings. R1 denied that R1 was injured during the day and did not realize there was an issue until staff informed R1.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20221012112740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 197606329
VISIT DATE: 10/19/2022
NARRATIVE
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A review of facility documents revealed that the mark was observed by staff and was noted in R1's daily notes. On 10/10/22, R1's doctor was notified of the bruise and was seen the following day of 10/11/22. A review of R1's most recent Individualized Program Plan, indicated that R1 does not require a one on one staff. The LPA was also able to review the staffing schedule, which indicated that there is always at least 2 staff available during the day and night.

Based on interviews and a review of facility documents, it is clear that R1 did receive an unexplained injury, however it was not due to staff negligence, therefore deeming this allegation UNSUBSTANTIATED.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2