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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609105
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:51:03 PM


Document Has Been Signed on 09/09/2022 12:51 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GRANDVIEW, THEFACILITY NUMBER:
197609105
ADMINISTRATOR:FLORES, YENIFACILITY TYPE:
740
ADDRESS:2211 W 6TH STREETTELEPHONE:
(213) 380-7000
CITY:LOS ANGELESSTATE: CAZIP CODE:
90057
CAPACITY:215CENSUS: 160DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Yeni FloresTIME COMPLETED:
01:00 PM
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During Licensing Visit at 10:30 AM LPA spoke with the facility staff and residents. Information received revealed the following;

On 09/07/2022, R1 was last seen by their roommate resident #2 (R2) roughly fifteen minutes prior to the incident, around the dinner time. R2 went for dinner and R1 did not wish to join R2. R2 grabbed dinner and returned to their room and needed to use the restroom, knocked on the door several times, and when R1 did not respond R2 opened the door saw R1’s feet outside of shower curtains. R2 alerted staff, and they found R1 hanging from the shower head using a belt. R1 was unhooked, staff called 911 and began CPR as they waited for paramedics to arrive. Paramedics arrived and resumed CPR but with no results. Police arrived, took the belt and corners arrived shortly after. The family of the deceased were notified, and responsible member stated that R1 had a previous incident.

During this visit at 11:30 AM, LPA requested and reviewed R1’s facility records. A review of records revealed that R1 had Mental Health problems and needed medication assistance. R1 did not require any assistance with other Activities of Daily Living (ADL) and was able to leave facility unassisted, able to care for personal needs and had no suicidal ideation.

LPA Duguma was informed that the Administrator has contacted a psychologist to speak with staff and residents.

No immediate health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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