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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426201
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:04:43 PM


Document Has Been Signed on 04/05/2022 05:04 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 MANORFACILITY NUMBER:
336426201
ADMINISTRATOR:JASON NAZARENOFACILITY TYPE:
740
ADDRESS:4411 CHICAGO AVENUETELEPHONE:
(951) 781-8400
CITY:RIVERSIDESTATE: CAZIP CODE:
92507
CAPACITY:82CENSUS: 69DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Administrator, Jason NazarenoTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA)’s, Janira Arreola and David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA's were greeted and granted entry by Administrator, Jason Nazareno who was informed of the purpose of the visit. At the time of visit there was 4 staff and 69 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA's were informed that no weapons or ammunition is maintained at the facility.

During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. During walk through of facility the following deficiencies were noted.

· Physical plan issues, water heater leaking and hole in wall located in hallway

Based on observations deficiencies will be given in LIC 809 D.

An exit interview was conducted, and a copy of this report and appeal rights were reviewed and provided to facility Administrator, Jason Nazareno.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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Document Has Been Signed on 04/05/2022 05:04 PM - It Cannot Be Edited

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: 336426201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(A)


This requirement is not met as evidenced by:During walthrough LPA's identified a hole in the wall near hall way and discovered a water heater to be leaking and in need of repair.
Deficient Practice Statement
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Based on observations , the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Facility will submit pictures and receipts of repairs to CCL by due date for deficiencies to be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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