336426201-5-13-2021-18-AS-NBRN-C3CTPR-20210525145443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426201
Report Date: 05/13/2021
Date Signed: 05/13/2021 01:42:10 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
09/15/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200915103110

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: 68	DATE:	05/13/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator Jason Nazareno		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained injury while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/13/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-inspection due to COVID-19 in order to deliver the finding to the above allegation. LPA Henry provided the finding to Administrator Jason Nazareno.

The investigation consisted on interviews and document review. Interviews revealed Resident 1 (R1) did not sustain an unexplained head injury while living at the facility. R1 has had a cyst on the left side of their forehead for more than 10 years. Based on interviews conducted, it was confirmed that R1 does not have an unexplained injury. This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted where this report was provided to Jason Nazareno.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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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