197609483-12-16-2024-31-AS-NMAN-DGUUQ9-20250520154647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609483
Report Date: 12/16/2024
Date Signed: 12/16/2024 02:38:51 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
11/13/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20241113133500

FACILITY NAME:	GRANDEUR		FACILITY NUMBER:	197609483
ADMINISTRATOR:	JOEY S. PEREZ		FACILITY TYPE:	735
ADDRESS:	2463 GRANDEUR		TELEPHONE:	(626) 314-2064
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	4	CENSUS: 4	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Co-Administrator Juana Ivett Busby		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff pushed resident
Staff speaks to resident in an inappropriate manner

INVESTIGATION FINDINGS:

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At 10:15a,m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the Direct Support Professional (DSP’s), Toekisha Myrick and Ruben Davis and explained the reason for the visit. DSP, Myrick contacted Co-Administrator via -phone and joined us.

During initial visit on 11/15/24 at 9:35a.m. LPA and DSP, Myrick conducted a physical plant tour. At approximately 9:45a.m. LPA interviewed staff #1 (S1) present at the facility. At 10:15a.m. LPA attempt to interview witness (W1) via-phone and at about 11:20a.m. LPA had a phone interview with staff #2 (S2). At approximately 10:30a.m. LPA request and received R1 record including but not limited to emergency contact Information, Referral Summary Records, Individual Program Plan (IPP), Unusual Incident Report, Appraisal Needs and Services Plan, Facility Daily Notes, staff and resident rosters. At 10:50a.m. LPA interviewed Co-Administrators in the facility.
Continue LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20241113133500

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: 12/16/2024

NARRATIVE

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At approximately 11:05a.m., LPA attempted to interview resident (R1) in the room, however; R1 refused to be interviewed. LPA asked questions relevant to the nature of the complaint.
Prior to this visit on 12/13/2024 LPA Antonia Alvizar-Ettima reviewed the documents previously obtained from the facility.

At the time of this visit at 10:20a.m., LPA Alvizar-Ettima and DSP, Myrick conducted a physical plan tour to ensure that there are no health and safety hazards.

Staff pushed resident.

It was alleged that staff #1 (S1) pushed resident (R1) in the kitchen because S1 thought R1 was going to do something to S1. During investigation, LPA attempt to interviewed resident (R1), however they refused to be interviewed. Co- Administrators and staff interviews reveal that staff did not push R1. S1 indicated that R1 was having aggressive and combative behavior, throwing a chair off the table while in the kitchen where S1 was using the stove. When R1 walked out of the kitchen, S1 pulled a couch as a barrier to prevent R1 from entering to the kitchen again to prevent R1 from hurting themselves and others. R1 attempt to enter the kitchen by standing on couch, then stepped back off the couch and lost balance landing on the living room floor. Staff asked R1 if they were hurt and R1 responded “no they are okay” and walked into their room. Co-Administrator spoke with R1 after the incident, and R1 never report or mention S1 pushing them. During today’s visit LPA did not observe staff pushing residents.

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

Staff speaks to resident in an inappropriate manner.

It was alleged that staff #1 (S1) yells, cusses and tells resident #1(R1) what to do. LPA attempt to interviewed resident (R1) however they refused to be interviewed. Co- Administrators and staff interviews reveal that they do not yell or cusses at residents and never witnessed S1 or other staff yelling at R1. Staff

Continue LIC -9099-C

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20241113133500

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: 12/16/2024

NARRATIVE

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indicated that they try to assist/remind R1 about their Activities of Daily Living (ADL’s) and R1 does not like it and gets upset, because R1 feels that S1 is telling them what to do. To remind R1 to complete ADL’s is part of R1’s Needs and Service Plan. LPA confirmed information provided by S1 on facility records. During investigation, LPA did not observe staff yelling and/or cussing at residents.

Based on interviews, observation, and record review, although the alleged incident may have happened, however, there is no sufficient information to conclude that “Staff yells, cusses at resident in care”. Therefore, the allegation deemed UNSUBSTANTIATED at this time.

No health and safety hazard is noted during this visit.

Exit interview is conducted and copy of report was provided.

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

LIC9099 (FAS) - (06/04)

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