<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609483
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:09:36 PM

Substantiated


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
07/28/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20210728152121
FACILITY NAME:GRANDEURFACILITY NUMBER:
197609483
ADMINISTRATOR:SMITH, JASONFACILITY TYPE:
735
ADDRESS:2463 GRANDEURTELEPHONE:
(855) 302-3331
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:4CENSUS: 4DATE:
09/08/2021
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ivett Busby, ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff sprayed resident's shirt with bleach
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent complaint visit to obtain additional information and to deliver the finding for the above noted allegation. LPA met with Ivett Busby, Manager. The purpose of the visit was discussed.

It was reported that facility staff sprayed resident #1 (R1's) shirt with bleach. To investigate this allegation on 08-03-2021 between 10:15am and 10:45am, LPA interviewed staff. Interviews revealed that about three weeks ago the washer was not working properly and that two (02) out of four (04) clients/ shirts were stained with bleach. Client # 1 (C1)'s shirt was stained with bleach and was not discarded. On 07-25-2021, C1 was wearing the stained shirt according to staff. At 12:00pm, C1 showed LPA the shirt stained with bleach. The shirt had large circular stains on both sides and looked old. C1 told LPA that facility staff sprayed them with bleach. The location and size of the stains is not consistent with someone spraying a shirt with bleach. On 08-12-2021, LPA spoke to Direct Support Professional #1 (DSP #1) by phone.
See 9099-C to continue
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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 3
Control Number 31-AS-20210728152121
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: GRANDEUR
FACILITY NUMBER: 197609483
VISIT DATE: 09/08/2021
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
26
27
28
29
30
31
32
Staff member denied spraying C1's shirt with bleach and told LPA that they were cooking and could not give attention to C1 on the day in question. According to staff, C1 became upset and made up the whole story out of frustration.

Investigation revealed that although it was not verified that S1 sprayed the bleach on C1's shirt, the facility staff admitted that due to the washer not working properly, two (02) clients' shirts were stained with bleach. LPA also observed C1's shirt to be stained with bleach.

Based on interviews and observation, there is sufficient information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Under Title 22 Regulations the following citation was issued and recorded on LIC 9099-D.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210728152121
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: GRANDEUR
FACILITY NUMBER: 197609483
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
CCR
80026(d)
1
2
3
4
5
6
7
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (d) Cash resources, personal property, and valuables of clients handled by the licensee shall be free from any liability the licensee incurs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator purchased a new washer on 8-31-21. The old washer will be discarded.
8
9
10
11
12
13
14
The Licensee did not ensure that C1's personal property was safeguarded as required. This poses a potential personal rights violation to residents 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3