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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005231
Report Date: 07/22/2022
Date Signed: 10/25/2022 03:23:00 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: 3DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Rozina Amlani, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1. Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report was amended. On 07/22/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility. LPA was greeted and granted entry by caregiving staff who called Rozina Amlani, Administrator, who arrived later to assist with the visit. It was alleged that Resident sustained injuries while in care. During the investigation it was discovered that Resident 1 (R1) sustained an unwitnessed fall on 02/01/2022. Interviews conducted with staff and facility Administrator confirmed that upon finding resident on the floor resident was observed able to stand up unassisted. R1’s responsible party was notified. No medical attention was sought at that time, however, R1 was later that day sent to the hospital after becoming unresponsive to staff. Medical records obtained and reviewed confirmed R1 sustained bruising to face. Per review of medical records submitted my Mission Hospital under subpoena conducted, R1 was noted to be a fall risk. This was later confirmed during an interview with facility Administrator. Therefore, based on preponderance of evidence gathered, the allegation that resident sustained injuries while in care is deemed to be substantiated. The following is being cited per Title 22 Division 6. Exit interview conducted and a copy of report and appeal rights were given to facility representative.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 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: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2022
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
The California Code of Regulations Section 87468.1(a)(2) states that residents are "to be accorded safe, healthful and comfortable accommodations."
This requirement is not being met as evidenced by interviews and file reviews conducted at the facility.
1
2
3
4
5
6
7
The licensee will assess the needs of prospective residents in order to confirm the level of care required is compatible with the care provided at the facility.
8
9
10
11
12
13
14
This poses an immediate Health and Safety risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2