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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609483
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:16:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
10/08/2024 and conducted by Evaluator Antonia Alvizar-Ettima
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241008100421
FACILITY NAME:GRANDEURFACILITY NUMBER:
197609483
ADMINISTRATOR:JOEY S. PEREZFACILITY TYPE:
735
ADDRESS:2463 GRANDEURTELEPHONE:
(626) 314-2064
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:4CENSUS: 4DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Co-Administrators Juana Ivett Busby and Cindy Garcia TIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff member physically abused resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced initial visit for the above noted allegation. LPA met with Direct Support Professional (DSP) Jorge Estrada and Toekisha Myrick and granted entry. The purpose of the visit was discussed. DSP, Estrada contacted Co-Administrators then later arrived to the facility and joined us.

At 10:35a.m. LPA and DSP, Contreras conducted a physical plant tour. Between 10:55a.m. – 11:40a.m LPA interviewed Co- Administrators, two (02) staff in the facility. At approximately 11:40a.m. LPA request and received staff and resident rosters. At 11:50a.m. LPA request and received R1 Information and Emergency, Living Options Committee Notes and Referral Summary, Individual Program Plan (IPP), Unusual Incident Report, Appraisal Needs and Services Plan, CPI Training Refresher, Facility Daily Notes and reviewed documents obtained. Between 12:22p.m. – 12:30p.m. LPA attempt to interview two (2) staff via-phone. At approximately 2:15p.m. LPA interviewed resident (R1) in the facility. LPA asked questions relevant to the nature of the complaint.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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 2
Control Number 31-AS-20241008100421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANDEUR
FACILITY NUMBER: 197609483
VISIT DATE: 10/11/2024
NARRATIVE
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Staff member physically abused resident in care.

It is alleged that staff (S1) did not properly used the Crisis Prevention Intervention (CPI) and got too aggressive with resident (R1). LPA interviewed resident (R1) and indicated that staff members do not physically abuse residents. R1 indicated that staff do use the correct CPI and are not aggressive. Co- Administrators and staff interviews reveal that staff only performed a Crisis Prevention Intervention (CPI) hold for 15 minutes with interval release when resident’s became aggressive. Co-Administrator, Garcia indicated hearing R1 was talking on the phone saying that staff did the right CPI and was not aggressive. R1 said that they were upset at time of the incident and did not want an investigation to be done. Staff indicated that the CPI is used to prevent a resident from hurting themself, staff and/or other residents in the facility. Staff indicated that they never physically abuse residents as a response to when residents are experiencing behavior issues. During today’s visit LPA did not observe staff being aggressive with residents.

Based on interviews, observation and record review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazard is noted during this visit.


Exit interview is conducted and copy of report was provided to Co – Administrator.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2