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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 03:27:59 PM

Unsubstantiated


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 lost 5 lbs a day for not eating.
INVESTIGATION FINDINGS:
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On 10/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent 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. 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 unsuccessful attempts to interview a resident (R1) and four (4) potential witnesses (W1-W4).

REPORT CONTINUED IN LIC 9099C
Unsubstantiated
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 2
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 lost 5 lbs a day for not eating.

It is alleged Resident #1 (R1) lost five (5) lbs a day for not eating. Based on R1's admission agreement, R1 was admitted to the facility on 8/8/2022. R1’s Physician's Report dated 7/26/2022 shows R1 weighed 103 lbs. There is no available record showing R1's current weight during the incident (9/8/2022). Based on LPA's interview with Staff (S1-S4) and Residents (R2, R6 and R7), they have not observed any residents losing five (5) lbs a day. Staff (S1-S4) stated R1's body frame is petite and R1's eats low- carb diet. LPA attempted to contact potential witnesses (W1-W4) to obtain additional information but LPA was unable to reach them. Based on LPA’s interviews and record review, there is no sufficient evidence to corroborate the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is Unsubstantiated

An exit interview was conducted with House Manager Albert Simon, and a hard copy of the report was 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 2