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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609483
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:07:40 PM

Document Has Been Signed on 12/16/2024 03:07 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANDEURFACILITY NUMBER:
197609483
ADMINISTRATOR/
DIRECTOR:		JOEY S. PEREZFACILITY TYPE:
735
ADDRESS:2463 GRANDEURTELEPHONE:
(626) 314-2064
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 4CENSUS: 4DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Co-Administrator Juana Ivett BusbyTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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In conjunction with complaint investigation, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the complaint.

During complaint #31-AS-20241113133500 investigation, between 9:45pm and 11:20am, LPA Alvizar-Ettima was informed that on 11/12/2024 staff #2 (S2) was sleeping in the living room couch while resident #1 (R1) having aggressive and combative behavior, throwing a chair off the table while in the kitchen where S1 was using the stove. Witnessed #1 (W1) had to tap S2 on their shoulder to wake them up to help S1 to redirect R1.

Based on the descriptions of the incident, S2 was asleep during their shift while R1’s aggressive and combative behavior was reflecting health, safety and well-being of S1 and W1 and other facility residents.
Therefore, Under Title 22 Regulations, the following citation is issued and recorded on LIC809D.

No other health and safety hazard is noted during this visit.
Exit interview was conducted. An appeal rights were discussed and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 03:07 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 12/16/2024 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: GRANDEUR
FACILITY NUMBER: 197609483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2024
Section Cited
CCR
85065(e)

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85065 Personnel Requirements
(e) The licensee shall provide for direct supervision of clients during participation in or presence at potentially dangerous activities or areas in the facility.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
Retrain staff and submit training signature sheet with a description of the training.
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Based on interviews, the licensee failed to provide adequated supervision to R1 while having aggressive and combative behavior, which poses a potential health and safety risk to staff, residents in care and visitors.
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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:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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