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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881456
Report Date: 11/13/2023
Date Signed: 11/13/2023 12:08:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231106141024
FACILITY NAME:GRANDVIEW MANORFACILITY NUMBER:
331881456
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:4411 CHICAGO AVETELEPHONE:
(337) 244-2252
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY:82CENSUS: 74DATE:
11/13/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Yusef Nofal, CaregiverTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not ensure resident's room was free of pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Javina George made an unannounced visit to commence a complaint investigation for the allegation noted above. LPA met with Yusef Nofal and explained the purpose of the visit and the elements of the allegation. The investigation consisted of observations, interviews, and records review.

On 11/06/2023, Community Care Licensing received an allegation that staff did not ensure resident's room was free of pests. On 11/13/23 LPA conducted a complaint visit, during the visit LPA conducted nine (9) resident interviews and seven (7) of the (9) residents confirmed that they had seen cockroaches at the facility specifically in the bathrooms, under their beds and corner of the walls, as recent as this morning going back to a couple of weeks ago. The residents reported that the cockroaches come in through the bathrooms and the vents inside the ceiling, in the resident bedrooms. The residents denied seeing and exterminator spray inside only outside, per Caregiver Yusef the exterminator either comes out every two weeks or once a month it depends on *** Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
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 5
Control Number 18-AS-20231106141024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRANDVIEW MANOR
FACILITY NUMBER: 331881456
VISIT DATE: 11/13/2023
NARRATIVE
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the season. LPA observed the exterminator invoices and the facility was last serviced on 10/16/23., and monthly going back to June 2023. Additionally while LPA was in a resident bedroom, LPA observed a cockroach that had been stepped on/smashed on the ground. Based on observations and interviews the allegation of staff did not ensure resident's room was free of pests is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report, and appeal rights were reviewed and provided to Yusef Nofal.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231106141024

FACILITY NAME:GRANDVIEW MANORFACILITY NUMBER:
331881456
ADMINISTRATOR:SHALABI, JAMALFACILITY TYPE:
740
ADDRESS:4411 CHICAGO AVETELEPHONE:
(337) 244-2252
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY:82CENSUS: 74DATE:
11/13/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Yusef Nofal, CaregiverTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility failed to keep the facility free from cigarette smoke.
Staff did not provide adequate meals to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Javina George made an unannounced visit to commence a complaint investigation for the allegation(s) noted above. LPA met with Yusef Nofal and explained the purpose of the visit and the elements of the allegation(s). The investigation consisted of observations, interviews, and records review.

On 11/06/2023, Community Care Licensing received an allegation that facility failed to keep the facility free from cigarette smoke. It was alleged that the facility failed to keep the facility free from cigarette smoke. LPA conducted a tour of the interior and exterior of the facility and observed for there to be four designated areas for the residents to smoke (2) areas as you exit the back doors and a patio in the courtyard in the middle of the facility and in the front of the facility by the tree. LPA did not smell any cigarettes or observe any smoke while inside the facility, which includes being inside some of the resident bedrooms. However a resident did state that due to the angle of their bedroom the smell of cigarettes would not come inside with their window being open. ***Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20231106141024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GRANDVIEW MANOR
FACILITY NUMBER: 331881456
VISIT DATE: 11/13/2023
NARRATIVE
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Per resident interviews there is no smoking allowed inside of the facility, only in the designated areas. Per Caregiver Yusef there are a lot of residents that do in fact smoke, but do so in the designated areas. Based on observations and interviews the allegation is UNSUBSTANTIATED.

Allegation: Staff did not provide adequate meals to resident in care.

It was alleged that the facility staff did not provide adequate meals to resident in care. On 11/13/23 LPA conducted a complaint visit during the visit, LPA conducted nine (9) resident interviews and four (4) of the nine (9) residents stated that the food that is served is cold, the portions are small, but allowed to have seconds and that there usually are a lot of flies flying around. LPA conducted a tour of the interior and exterior of the facility. LPA observed for the back doors to be propped open by the residents who were going in and out of the building to smoke. The front door is also propped open. The door would be closed and then opened back up again. LPA was present while lunch was served and the food was observed to be hot, as there was steam visibly observed coming from the food.

LPA did observe for there to a fly, flying around in the dining room. Per Caregiver Yusef the Cook is not allowed to prepare meals hours in advance, The meals are prepared within a 1-2 hour window, and it depends on what is being served. LPA conducted a tour and observed at 9:45am for the meatloaf to be in the oven baking. Lunch is served 11:00am-12:00pm. Based on observation and interviews the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.


An exit interview was conducted where a copy of this report, was reviewed and provided to Yusef Nofal.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20231106141024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRANDVIEW MANOR
FACILITY NUMBER: 331881456
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2023
Section Cited
HSC
1569.269)a)(5)
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ENUMERATED RIGHTS: SEVERABILITY Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not met
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The Licensee agrees to have the exterminator come and treat the deisignated areas such as the bathrooms inside resident room. The licensee is to submit receipts or invoice to CCL by 5pm on the due date indicated.
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as evidenced by: 7 of 9 residents confirmed that there are in fact roaches at the facility. This is an immediate Health and Safety risk to residents in care.
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CCR
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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5