197609105-4-28-2021-31-AS-NGID-C4BT3C-20210625142206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609105
Report Date: 03/29/2021
Date Signed: 04/28/2021 08:25:39 AM

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
03/19/2021 and conducted by Evaluator Naira Margaryan

COMPLAINT CONTROL NUMBER: 31-AS-20210319092558

FACILITY NAME:	GRANDVIEW, THE		FACILITY NUMBER:	197609105
ADMINISTRATOR:	FLORES, YENI		FACILITY TYPE:	740
ADDRESS:	2211 W 6TH STREET		TELEPHONE:	(213) 380-7000
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90057
CAPACITY:	215	CENSUS: 139	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Yeni Flores		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident was mentally and emotionally abused by another resident while in care

INVESTIGATION FINDINGS:

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This is an amended copy of the previous complaint report issues on 03/29/2021. The document was amended to add additional information reported to the Licensing Office.
Licensing Program Analyst (LPA) Naira Margaryan initiated a complaint investigation for the above noted allegation.
Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face-time. The purpose of this tele-visit was explained to the Administrator.
It was reported that client #1 (C1), was mentally and emotionally abused by their roommate client #2 (C2). C2 was making ongoing threats to get C1 evicted as well as deported. C2 was trying to control C1, screaming at C1 and using derogatory language.
During this visit, between 10:00am and 11am, LPA Margaryan spoke with the Administrator and other staff and they verified that there was a conflict between C1 and C2.
At 10:30am LPA Margaryan spoke with C1 and C2. Between 11:30am and 12:30pm, LPA Margaryan spoke with other witnesses, that were involved in C1’s and C2’s care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210319092558

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: GRANDVIEW, THE	FACILITY NUMBER: 197609105
	VISIT DATE: 03/29/2021

NARRATIVE

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Interviews verified that C2 was trying to control C1. C2 was threatening C1 and emotionally abusing them.
A review of the facility records conducted at 1:30pm, revealed that C2 was having a problem not only with C1, but also other facility clients and staff.
Based on interviews and record review, there is a sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under title 22 regulations, following citations were issued and recorded on LIC9099D.

No other issues were noted during this visit.

Telephonic exit interview was conducted, and a copy of report was e-mailed to the Administrator for review and manual signature.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210319092558

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: GRANDVIEW, THE	FACILITY NUMBER: 197609105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/02/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement is not met as evidenced by;	1 2 3 4 5 6 7	The Administrator will provide written plan of action explaining how they will make sure that no client will be subject to of humiliation and abuse. POC will be submitted by POC due date.
	8 9 10 11 12 13 14	Based on the interviews and record review, Licensee did not assure that clients are free of humiliation and abuse. The client C1 was mentally and emotionally abusing client C1. This posses potential health and safety hazard to the clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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