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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320218
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:18:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20220912165148
FACILITY NAME:GRANDVIEW GUEST HOMEFACILITY NUMBER:
198320218
ADMINISTRATOR:SANTOS, JENNICE-RAE RUTAFACILITY TYPE:
740
ADDRESS:2444 235TH STTELEPHONE:
(310) 782-5045
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:ALBERT SIMONTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident eloped from facility.
INVESTIGATION FINDINGS:
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On 10/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Licensee Coty Cabral. The facility is free of Covid-19 infection. The facility is free of Covid-19. LPA met with Staff Floradima Suasa (S3), Staff Elizabeth Vergara (S4) and Staff Alberto Simon. LPA explained the purpose of the visit.

The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Staff Elizabeth Vergara (S4). LPA observed three (3) staff and six (6) residents during the visit. LPA interviewed S4. LPA made an unsuccessful attempt to interview a resident (R1) and four (4) potential witnesses (W1-W3).

REPORT CONTINUED IN LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 3
Control Number 11-AS-20220912165148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218
VISIT DATE: 10/07/2022
NARRATIVE
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INVESTIGATIONS REVEALED:

ALLEGATION: Resident eloped from facility.

It is alleged Resident #1 (R1) eloped from facility. Reporting Party stated, "R1 presents with mild insight and awareness and recalls eloping from Grand View Guest House due to poor treatment”. Based on LPA’s review of R1’s admission agreement, R1 was admitted to the facility on 8/8/2022. Physician’s Report shows R1 is ambulatory and has dementia. It also stated that “R1 is not Able to Leave Facility Unassisted”. Based on interviews and record reviews conducted, Staff (S1-S3) admitted R1 left the facility on 9/8/2022 without staff knowledge and supervision. S1 revealed R1 was located by police officers inside Bank of America in Santa Monica. S1 stated R1 did not return to the facility. Based on LPA’s interviews and record reviews conducted, there is sufficient evidence to corroborate the above allegation.

Based on LPA observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and Appeal Rights was discussed with House Manager Albert Simon. A hard copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220912165148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2022
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by:
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The licensee will submit a plan of correction outlying steps to take to ensure that Dementia residents do not elope from the facility in the future. POC will be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/8/2022.
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Based on interviews and record reviews conducted, Resident #1 eloped from the facility without supervision. This poses an immediate risk to health, safety and/or personal rights of residents in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3