<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320218
Report Date: 11/30/2022
Date Signed: 12/01/2022 08:02:21 AM

Document Has Been Signed on 12/01/2022 08:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:COTY CABRALTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/302022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Montoya conducted a risk assessment with Licensee Coty Cabral who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Alberto Simon and explained the purpose of today’s visit.

The facility is licensed for age range 60 and over; approved for six (6) non-ambulatory, of which 1 may be bedridden; hospice waiver approved for three (3) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) bathrooms, one (1) living area, one (1) dining area, laundry area, kitchen, and covered outside patio. There is an attached garage used for storage only.

LPA Montoya toured the facility with House Manager Alberto Simon. Licensee Cabral arrived later and joined the visit. During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The water temperature measured at 117.2 degrees Fahrenheit. A comfortable temperature was maintained in the facility.

LPA observed the facility is appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Smoke detectors and carbon monoxide were operable.

Report continued in LIC809C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Licensee Coty Cabral.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/01/2022 08:02 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/30/2022 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed the toilet in the nonprivate bathroom is dirty and filthy in between the top of the toilet and the commode which is not removable. LPA also observed two fire extinguishers were not serviced annually. They were last serviced on 8/30/2021. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
1
2
3
4
Licensee shall ensure the facility is always clean and sanitary. Licensee agreed to clean the toilet. Licensee shall ensure the fire extinguishers are serviced annually for safety. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/12/2022.
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed one non-operable night light in the hallway to the nonprivate bathroom. Due to the distance of the bathroom, LPA advised the licensee to install two more night lights in the passages from bedroom #1 and #2.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2022
Plan of Correction
1
2
3
4
Licensee shall ensure there are operable night lights in the hallways to nonprivate bathroom. Licensee installed two night lights in the hallways to the nonprivate bathroom and changed the batteries of the nonoperable night light. This deficiency is corrected during today's visit.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/01/2022 08:02 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/30/2022 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GRANDVIEW GUEST HOME
FACILITY NUMBER: 198320218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee admitted when asked that the facility does not have a liability insurance coverage. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
1
2
3
4
Licensee shall obtain a liability insurance to comply to the regulation cited herein. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/26/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4