331881456-9-6-2024-18-AS-VMIN-D8UTQM-20240906145611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881456
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:56:43 PM

Document Has Been Signed on 09/06/2024 02:56 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GRANDVIEW MANOR		FACILITY NUMBER:	331881456
ADMINISTRATOR:	SHALABI, JAMAL		FACILITY TYPE:	740
ADDRESS:	4411 CHICAGO AVE		TELEPHONE:	(909) 781-8400
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92507
CAPACITY:	82	CENSUS: 80	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	LEAD CAREGIVER, ALICE SANTOS		TIME COMPLETED:	03:00 PM

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On September 6, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Lead Caregiver, Alice Santos, introduced herself and stated the purpose for the visit. The File review was conducted in the Regional Office and additional forms were requested and reviewed on site.

LPA Mixson toured the facility along with the Lead Caregiver and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit.

PHYSICAL PLANT: The facility is a 41-room facility located at 4411 Chicago Ave Riverside CA. 92507. Phone number is (909) 781-8400 and is operable.

Facility is licensed for 82 Elderly Adults and is operating at 80 which is within the conditions and limitations of the license. LPA Mixson observed the residents’ bedrooms, and each was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" and the "Personal Rights." The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean. LPA Mixson observed the required two-day supply of perishable and seven-day supply of non-perishable foods.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GRANDVIEW MANOR	FACILITY NUMBER: 331881456
	VISIT DATE: 09/06/2024

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Care & Supervision/Administration: Adequate staffs are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses an administrator certificate that they have paid for a renewal as the expiration date was 08/30/2024 but has submitted the updated renewal.

Record Review and Resident/Staff Files: LPA Mixson reviewed four staff files and reviewed the facility's staff schedule. Of the staff files reviewed LPA observed criminal clearance and updated training along with CPR/First Aid Certification. Eight resident files were reviewed and possessed required paperwork and include resident safeguards for valuables.

MEDICATION: Medications were reviewed and seen to have labels and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to residents in care. Medications and medication documentation was observed to be well organized and monitored.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards and was conducted on 04/30/2024.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. Temperature and sign in stations.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was discussed and given to Lead Caregiver, Alice Santos.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC809 (FAS) - (06/04)

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