336426201-6-17-2020-18-AS-NBRN-BQVV8Z-20200624161332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426201
Report Date: 06/17/2020
Date Signed: 06/17/2020 01:58:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/29/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200529130421

FACILITY NAME:	GRANDVIEW MANOR		FACILITY NUMBER:	336426201
ADMINISTRATOR:	JASON NAZARENO		FACILITY TYPE:	740
ADDRESS:	4411 CHICAGO AVENUE		TELEPHONE:	(951) 781-8400
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92507
CAPACITY:	82	CENSUS: 66	DATE:	06/17/2020
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Alice Santos, Office Manager		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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-Staff did not obtain medical attention for resident in care.
-Staff illegally evicted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Goldenberg conducted this investigation visit telephonically due to Covid-19 to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Alice Santos, Office Manager.

During the course of the investigation, LPA conducted a file review which included a review of the facility house rules. Interviews were conducted with three (3) staff and one (2) residents. A review of resident (R1) records was completed by LPA and copies of pertinent documents were obtained. LPA reviewed R1's physician's report, medication record for April, supervisory notes, needs and service plan, and an eviction notice. LPA also reviewed unusual incidents reported by the facility to Community Care Licensing.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020

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 18-AS-20200529130421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 336426201
	VISIT DATE: 06/17/2020

NARRATIVE

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It is alleged that R1 had a fall following seizure activity and the staff did not obtain medical attention. Based on review of the aforementioned LPA learned the following:

Supervisory notes and review of reported incidents did not reveal any documented information regarding R1 having a fall, accident, injury or seizure activity. Review of R1's physician's report and medication treatment records do not identify R1 as having a diagnosed seizure or displaying any seizure type activity. Interviews conducted did not reveal any corroboration or witness to the alleged incident.

It is alleged that R1 was illegally evicted. LPA reviewed the 30 day notice, house rules and supervisory notes and verified that R1 was evicted for not following the house rules.

We have found the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

A copy of this report is being reviewed with, and furnished to the facility representative Alice Santos via fax.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2020

LIC9099 (FAS) - (06/04)

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