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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005231
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:55:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20220204135802
FACILITY NAME:GRAND VIEW VILLAFACILITY NUMBER:
306005231
ADMINISTRATOR:AMNALI, ROZINAFACILITY TYPE:
740
ADDRESS:26701 GRANVIA DRIVETELEPHONE:
(949) 600-7218
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rozina Amlani, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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1. Resident sustained injuries while in care.

2. Facility did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
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On 06/09/2022 at 1:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of investigating complaint #22-AS-20220204135802. LPA was greeted and granted entry by facility administrator Rozina Amlani after being screened for COVID-19 and explaining the purpose of the visit.
LPA requested and obtained staff training records as well as the personnel files for caregivers S1 and S2. Personnel files include all required components and documentation of mandatory training is included. Onboarding training includes a discussion of emergency procedures which does not include the conduct expectation for serious incidents involving the health and safety of residents.
An interview with staff member S1 and administrator was also conducted by LPA. Interviews confirm that no 911 call was made at the time of the resident's initial fall and that emergency paramedics were only notified much later when the resident became lethargic
CONTINUED ON FORM LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20220204135802

FACILITY NAME:GRAND VIEW VILLAFACILITY NUMBER:
306005231
ADMINISTRATOR:AMNALI, ROZINAFACILITY TYPE:
740
ADDRESS:26701 GRANVIA DRIVETELEPHONE:
(949) 600-7218
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rozina Amlani, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
3. Facility staff was unable to communicate with emergency personnel due to a language barrier.
INVESTIGATION FINDINGS:
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On 06/09/2022 at 1:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of investigating complaint #22-AS-20220204135802. LPA was greeted and granted entry by facility administrator Rozina Amnali after being screened for COVID-19 and explaning the purpose of the visit.
LPA requested and obtained staff training records as well as the personnel files for caregivers S1 and S2. Personnel files include all required components and documentation of mandatory training is included.
An interview with staff member S1 and administrator was also conducted by LPA on this day. Despite limited fluency, staff are are knowledgeable in what they are required to do and are compentent to do so.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to the administrator Rozina Amlani.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20220204135802

FACILITY NAME:GRAND VIEW VILLAFACILITY NUMBER:
306005231
ADMINISTRATOR:AMNALI, ROZINAFACILITY TYPE:
740
ADDRESS:26701 GRANVIA DRIVETELEPHONE:
(949) 600-7218
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rozina Amnali, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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2
3
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5
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8
9
4. Facility staff was not aware of resident's DNR status.
INVESTIGATION FINDINGS:
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On 06/09/2022 at 1:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of investigating complaint #22-AS-20220204135802. LPA was greeted and granted entry by facility administrator Rozina Amnali after being screened for COVID-19 and explaning the purpose of the visit.
At approximately 1:30pm, LPA requested and obtained the resident file for resident R1. File includes all necessary components as marked in the attached record review. As corroborated by the reviewed admission agreement, the resident was not under a Do Not Resuscitate order at the time of the incident.
LPA has investigated the complaint alleging staff was not aware of the resident's DNR status. LPA has determined that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220204135802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRAND VIEW VILLA
FACILITY NUMBER: 306005231
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited
CCR
87465(g)
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Section 87465(g) Incident Medical and Dental Care "The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health (...)".
This requirement is not met as evidenced by the observation, file review and interviews
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Licensee agrees to include a formal training by 06/22/2022 on serious incident procedure and appropriate emergency medical services activation into the ongoing monthly training program, in addition to the corrected instructions already provided to staff.
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which establish that licensee did not activate the paramedics until several hours after the incident when resident became lethargic. This poses an immediate health and safety risk to the clients 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220204135802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GRAND VIEW VILLA
FACILITY NUMBER: 306005231
VISIT DATE: 06/09/2022
NARRATIVE
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Based upon observation, a review of records and interviews, the preponderance of evidence standard has been met and the allegations that the resident sustained injuries while in care and that facility did not seek timely medical attention are substantiated.

A deficiency is being cited in regard to the substantiated allegations and is being detailed in the attached form LIC9099-D. An exit interview was conducted and a copy of this report and appeal rights were given to the administrator Rozina Amlani.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5