197609105-7-22-2021-31-AS-LQLY-C572UW-20210722174257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609105
Report Date: 07/15/2021
Date Signed: 07/22/2021 05:43:52 PM

Document Has Been Signed on 07/22/2021 05:43 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, 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: 140	DATE:	07/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Yeni Flores		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 9:45am to conducted a One (1) year Required Infection Control visit. LPA meet with the administrator and explained the purpose of this visit. A tour of the physical plant was conducted at 10:00am and the following was observed: The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) posted and hand sanitizers wall mounted throughout the facility. The PPE screening station is located in the administration front desk office equipped with sufficient PPE readily accessible a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are allowed in the facility in residents rooms or in the common areas, activity room or outside patio shaded area with benches for seating. Fire Extinguishers located through out the facility first, second and third floor all serviced dated May 7, 2021. At 11:30am the fire alarm system was tested and observed to be working, it is hard wired and they have a water sprinkler system. The facility has four (4) First Aid kit storing locations. The medication room, administration office, kitchen and room 126 which is the shower room also equipped with PPE. The facility has an approved mitigation plan on file. Kitchen: The kitchen was observed to be clean and an adequate supply of perishables and non-perishable food was located in the fridge, freezer and pantry. Food was properly labeled and stored. The emergency food is stored and observed to locked in a room labeled "Emergency Plan" across from the elevator and sprinkler valve room. Trash cans were observed to be open without a lid. Lunch is staggered and served in individual plastic bags to maintain social distancing, lunch may be taken on the go or seated if room permits. Sharps are stored in the kitchen inaccessible to residents. (Continued on LIC 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/15/2021

NARRATIVE

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Storage Rooms: LPA observed four (4) locked storage rooms: Storage one (1) located at the entrance to the right in the tv room has been built to storage for PPE and facility toiletries. Storage two (2) located across from the medication room which is stocked with toxins, trash bags and other cleaning supplies. Storage three (3) located across from the medication room stocked with sufficient supply of linen individually wrapped in plastic protective covering.
Client Rooms: Rooms numbers 118: slow water drainage in sink and shower grab bars loose, 123: slow water drainage in sink, 141: slow toilet flush, shower grab bars loose. They all were observed on the second floor to be clean and appropriately furnished and without trash can lids. Water temperature on second floor range from 105.9 to 117.3 Rooms number 201, 226 246 were all observed on the third floor to be clean and appropriately furnished and without trash can lids. Water temperature range from 105.4 to 110.2 The emergency response cord were pulled and tested in all of the rooms which received a response within ten seconds from the front desk. No hospice residents at the time of visit.
Laundry Room: Located on the first floor observed to be clean and clear from obstruction. Residents are allowed to do there own laundry if they choose, all laundry soap is locked in storage and is given by staff from the locked storage room if needed.
Living, dining room and common areas: Observed to have sufficient tables and chairs for seating. Social distancing mark on floor.
Part of the parking lot is being used to store remolding supplies and flooring materials. No resident access to the parking lot. It is gated and requires entry into the facility.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/22/2021 05:43 PM - It Cannot Be Edited

Created By: LaQueena Lacy On 07/15/2021 at 02:42 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANDVIEW, THE	FACILITY NUMBER: 197609105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Water supplies and plumbing fixtures shall be maintained. Grab bars shall be maintained for each toilet; bathtub and shower used by residents. Based on the LPA observation during the physical plant tour, grab bars in room 118, 141 and 226 were loose and not sturdy for use. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Evaluate all grab bars in all rooms, make sure all are tighten and/or replaced if they need to be replaceed, to secure the safety of all residents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Naira Margaryan

LICENSING EVALUATOR NAME:

LaQueena Lacy

LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC809 (FAS) - (06/04)

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