The Grandview

Allegation investigated: Resident fell sustaining multiple bruises due to staff neglect.

On 7/15/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Yeni Flores and stated the reason for their visit. To investigate the allegation(s), at approximately 10:00 AM, LPA conducted a physical plant tour. By 10:30 AM, LPA requested relevant documentation such as but not limited to: Unusual Incident/Injury Report (SIR), Physician’s Report, Needs/Services, and Pre-Appraisal. From 10:30 AM to 12:30 PM, LPA attempted to interview one (1) resident (R1), seven (7) staff members (S1-S7), and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Resident fell sustaining multiple bruises due to staff neglect. It was alleged R1 fell resulting in bruising due to staff neglect. To investigate the allegation, LPA attempted interviews with one (1) resident and seven (7) staff members. LPA attempted to interview R1, but they were not present during LPA’s visit. S1 informed LPA, R1 has not returned from the hospital due to them seeking a new placement. LPA’s interview with six (6) of the seven (7) staff members revealed they did not witness nor were they made aware R1 to have fallen on 6/27/2026. Further interview with all seven (7) staff members confirmed if a resident were to fall, they are to be assisted if able and the fall is to be reported. LPA’s interview with S1 revealed that R1 had not disclosed to them that they had fallen. Per S1, they were made aware of R1’s bruising by R1’s family member on 7/02/2026. S1 stated once they became aware of R1’s alleged fall and bruising they sent them to the hospital that same day on 7/02/2026. Additionally, S1 took photos of R1’s injuries which LPA was shown and verified. During LPA’s record review, LPA observed the facility had self-reported the alleged incident on 7/03/2026 to their assigned LPA at Community Care Licensing Division (CCLD). Further record review of R1’s Physician’s Report revealed R1 was independent in their Activities of Daily Living (ADLs) such as: Bathing, grooming, feeding, and toileting needs. R1’s Physician’s Report revealed R1 to have various diagnosis. LPA’s web search of said diagnosis revealed the following: “patients frequently experience bruising, including under their arms. This is commonly caused by the use of blood thinners (like heparin) during treatments, skin fragility, and the natural blood-clotting issues associated with kidney disease”. LPA’s record review of R1’s Medication Sheet confirmed R1 to be on blood thinner medication. During LPA’s physical plant tour, LPA observed the dining area to have two (2) surveillance cameras. However, when LPA attempted to review the footage of 6/27/2026, the video surveillance did not have said footage available. Per S1, the facilities cameras are not set up to store footage past a certain allocated timeframe. LPA’s tour of R1’s bedroom revealed the room to be free of tripping hazards in the walkways and bathroom. During LPA’s physical plant tour, LPA observed a variety of staff to be present and assisting residents. LPA observed both floors of residents’ living quarters to be clean and free from tripping hazards. Based on interviews, record review, and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 31-AS-20260707081644

Allegation investigated: Staff do not follow proper eviction procedures.

On 4/21/26, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent facility visit regarding the above allegation. LPA conducted the initial complaint visit on 11/04/25, at which time LPA spoke with the facility Administrator. Between 12:30 pm to 1:15 pm, LPA recieved and reviewed facility roster, staff roster, and Resident#1's (R1’s) facility records, included but not limited to, physician report, needs and service plan, and other doculments relevant to the investigation. Between 1:35 pm and 2:15 pm, LPA interviewed R1. Allegation: Staff do not follow proper eviction procedures. It was alleged that R1 cannot return to the facility due to their substance use disorder. No notice of the eviction was issued to R1, due to R1 being in the medical facility. During today's subsequent visit, At 1:35 pm, LPA again spoke with Administrator and R1. During initial licensing visit, and at the time of this subsequent visit, R1 was still present in the facility. [LIC 9099C] Continued- Unsubstantiated LPA Interviews with Administrator and R1 revealed that the staff spoke with R1 about house rules informing them that continued noncompliance with facility house rules may lead to eviction. The Administrator revealed that they are continuing to work with R1 and assisting them to prevent possible eviction. Per Administrator, R1 has been compliant while living in the community. R1 verified the information received from the Administrator. Based on interviews and record review, there is not sufficient information to support the allegation. Hence, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard were observed at the time of this visit. Exit interview was conducted, and a copy of report was issued.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 31-AS-20251029115400

Allegation investigated: Staff did not prevent residents from engaging in a verbal altercation. Staff did not prevent a resident from hitting another resident with an object resulting in injury.

On Thursday, 2/19/26, Licensing Program Analyst (LPA) Raymond Comer, conducted an unannounced initial complaint visit to the facility. LPA met the Administrator, presented official CDSS badge identification, and reason for the visit was disclosed. At 9:45 am, LPA conducted a physical plant tour; no health and safety issues were observed. To investigate the allegation, LPA received facility resident roster, staff roster. Between 10:00 am, and 10:30 am, LPA observed surveillance camera recordings of the outdoor courtyard commons area. Between 10:45 am, and 12:50 pm, LPA conducted interviews with the Administrator, Residents, and Staff. Between 1:00 pm, and 1:30 pm, LPA reviewed files relevant to the investigation. Prior to this visit, LPA reviewed Licensing records, including incident reports submitted by the facility. LIC 9099C] Continued- Unsubstantiated Allegation: Staff did not prevent residents from engaging in a verbal altercation. Allegation: Staff did not prevent a resident from hitting another resident with an object, resulting in injury. LPA conducted an interview with the RP, which revealed the following: Per the RP, R1 reported to their Primary Care Physician (PCP) that R2 slapped R1 in the face, attempted to grab R1's clothing in the torso area, and pulled R1's hair. Although the allegation states that "lack of supervision" resulted in R1 being assaulted by R2, the RP states that R1 did not report any supervision issues to either the RP, nor R1's PCP. LPA conducted interviews with the Administrator, and Staff, which revealed the following: The incident occurred on the morning of 7/10/25, around 9:00 am. Both administrator and staff state that an argument was heard between R1 and R2 coming from their shared bedroom. The Administrator denies that "lack of supervision" was a factor in the incident. This incident was the first time that interactions between R1 and R2 resulted in any physically aggressive action. R1 has a history of confusion, but has never acted in an aggressive manner. Per Administrator, and Staff, R2 prefers to stay in their room most of the day reading and watching television. R2 does not socialize amongst the community, is easily provoked to react with verbal insults, but has no history of being aggressive towards either residents or staff. Per the Administrator, and Staff, R1 and R2 were heard arguing, prior to any physical altercation, and staff immediately attempted to de-escalate the situation. It was at this time that R2 suddenly reacted, slapping R1. According to both the Administrator, and Staff, neither residents sustained any injuries during the conflict. Per Admin, R1 has been moved to a different bedroom and assigned a new resident roommate. LPA conducted interviews with ten residents. Nine (9) out of ten (10) residents could not confirm the allegation that lack of supervision resulted in physical assault committed between residents. Although there was an altercation between R1 and R2, leading to R2 striking R1, there is not corroborating evidence to support the allegation, as staff were present to intervene and redirect both residents. Moreover, licensee did submit an Incident Report (IR) to the Licensing agency regarding the incident. Therefore, based on the information obtained, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 31-AS-20260211143028

Allegation investigated: Staff neglect resulted in a resident sustaining a pressure injury. Staff did not seek timely medical attention for a resident.

On Thursday, 1/15/26, Licensing Program Analyst (LPA) Raymond Comer, conducted an announced complaint visit to the facility. LPA met the Administrator and discussed the purpose of this visit. During investigation at 2:00pm, LPA conducted physical plant tour. LPA spoke with the Administrator and two (2) staff. Due to nature of allegations, from 2:15pm to 2:45pm, LPA Comer spoke with ten (10) out of hundred fifty eight (158) facility residents including R1. During interview, LPA observed and assessed R1 and did not notice any wound on their arms. Prior to this visit LPA reviewed Licensing records including incident reports submitted by the facility. Allegation: Staff neglect resulted in a resident sustaining a pressure injury. Allegation: Staff did not seek timely medical attention for a resident. [LIC9099C]-continued Unsubstantiated It was reported that on 01/11/26, Resident #1 (R1) was at urgent care for post fall evaluation and observed with an open wound on their arm. R1 did not receive timely medical treatment for the wound and was unable to recall how long they had a wound. Staff revealed that on 01/11/26, R1 had an un-witnessed fall and complained of pain in their left arm. Staff #1 (S1) assessed R1’s for pain and no wounds were noted on R1’s arms. Due to pain, staff called an ambulance and R1 was transported to the hospital for evaluation. Staff also revealed that they received a call from the hospital informing that R1 observed having a big cut on their arm and staff explained to the caller that they did not observe a cut on R1’s arm. Upon R1’s return, staff checked R1’s arm and noticed a small cut that could have resulted from the drawing of blood. LPA interviews with residents revealed the following: R1 and other residents did not address any concerns about their care and medical attention provided by the facility staff. A review of R1’s facility records revealed that R1 is independent resident and does not require care and supervision to retain activities of daily living. A review of incident report dated 01/11/26 involving R1 verified the information revealed by staff. Overall investigation did not reveal any pertinent information to verify the allegations. Therefore, based on interviews, observation and record review, the above noted allegations are UNSUBSTANTIATED at this time. No health and safety issues were noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 31-AS-20260113095023

Type of visit: Case Management - Annual Continuation

On Friday, 9/05/25, Licensing Program Analyst, (LPA) Raymond Comer, arrived to continue the required annual Inspection initiated on 08/28/2025. LPA met with Administrator, Yeni Flores, and the purpose of visit was disclosed. The following remaining domains were observed, reviewed and inspected: Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Six (6) resident rooms (#106, #114, #146, #229, #235, #250) were inspected and observed to maintain required furnishings, sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary, with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 108°F and 110°F; within the required range. Medications: Medication room is located on first floor. LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Resident medication documentation and distribution records appear to be accurate and complete. Commons: Activity room, and dining room observed as clean and clear of obstruction. Furnishings observed to be in good condition. No tripping hazards observed. [Continued on LIC 809-C] Outdoor: Courtyard area observed to have a shaded area, with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Required - 1 Year

On 8/28/25, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer conducted an unannounced annual visit to this facility. LPA met with the Administrator and reason for the visit was disclosed. Facility is licensed as a multi-story residence. Fire clearance for two hundred and fifteen, (215) non-ambulatory residents; sixteen (16) of which may be bedridden. Hospice Waiver approved for two (2) residents. At 10:25 am, LPA conducted the tour of the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 05/2025. Fire Detection/Protection system is present in the facility. Smoke and carbon monoxide detectors are hardwired, interconnected. System was tested and passed inspection certified by Los Angeles Fire Department on 03/05/2025. Fire Extinguishers are located throughout the facility and were serviced on May 17, 2025. (LIC 809-C continued) Kitchen: LPA observed kitchen to be clean, maintaining an adequate supply of perishable and non-perishable food located in the fridge, freezer, and pantry. Food was properly labeled and stored. The emergency food is stored and observed to locked in a room labeled "Emergency Plan" across from the elevator and sprinkler valve room. Trash cans observed with lids. Sharps are stored in the kitchen and inaccessible to residents. Laundry: LPA observed two (2) laundry rooms, located on the sub-base level floor, to be clean and clear from obstruction. Residents are allowed to do their own laundry if they choose, and industrial laundry machines were observed to be locked and used by staff only. All laundry soap is locked in storage and is given by staff from the locked storage room if needed. Resident records: Facility records room was observed as locked and inaccessible to residents. A total of nine (9) resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Facility records room was observed as locked and inaccessible to residents. A total of eight (8) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. There were no health and safety hazards observed at the time of this inspection. Due to time constraints, LPA was unable to complete this required annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report given to Administrator.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

On 11/23/24, 09:15 am, Licensing Program Analysts, (LPAs') Raymond Comer, and Jose Gary Tan, conducted an unannounced annual visit to this facility. LPA met with Office Manager Jaime Trejo, who coordinated communications with Facility Administrator, Yeni Flores. LPA's spoke with the Administrator, via cellphone. Reason for the visit was disclosed and Administrator designated Mr. Trejo to sign the report Facility is licensed as a multi-story residence; the facility is fire cleared for two hundred and fifteen, (215) non-ambulatory residents; sixteen (16) of which may be bedridden. At 09:35 am, LPAs conducted the tour of the physical plant with Mr. Trejo, and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Room temperature is comfortable; wall thermostat displays a setting of 73.0°F., within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted on 11/02/2024. Fire Detection/Protection system is present in the facility. Smoke and carbon monoxide detectors are hardwired, interconnected and observed to be tested as "passed" inspection by Los Angeles Fire Department on 02/26/2024. Fire Extinguishers are located throughout the facility; all serviced May 15, 2024. (LIC 809-C continued) Kitchen: At 10:10 am, kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in the fridge, freezer, and pantry. Food was properly labeled and stored. The emergency food is stored and observed to locked in a room labeled "Emergency Plan" across from the elevator and sprinkler valve room. Trash cans observed with lids. Sharps are stored in the kitchen inaccessible to residents. Medication: At 10:35 am, LPAs' observed medications room to be secured and inaccessible to residents. Medications are stored in clear bins, refrigerator, and medication carts. Medication is prepared for residents and then placed in medication carts observed to be locked until distribution in the front office inaccessible to residents. Laundry: At 11:50 am, LPAs observed two (02) laundry rooms, located on the sub-base level floor, to be clean and clear from obstruction. Residents are allowed to do their own laundry if they choose, and industrial laundry machines were observed to be locked and used by staff only. All laundry soap is locked in storage and is given by staff from the locked storage room if needed. Commons: At 12:10 pm, LPAs observed community room, and activities room, to have sufficient tables and chairs for seating. Outside and surrounding area of the facility observed to be clean and clear from debris and obstruction. Bedrooms At 10:53am LPAs observed random rooms with bathrooms located inside on the first and second floor to be appropriately furnished with sufficient lighting, bed linen and comforters on all beds. Bedrooms contain single and double occupancy. All bedrooms observed to be clean and clear from obstruction. Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperatures were measured randomly in multiple room;average temp range 107.8 - 114.0°F.; Within the required range. Hand towels are not shared. [LIC 809C] Continued-- Resident records: Facility records room was observed as locked and inaccessible to residents. A total of eights (8) resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current. Staff records: Facility records room was observed as locked and inaccessible to residents. A total of seven (7) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Nov 23, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff pushed resident

Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPAs met with the administrator, Yeni Flores, and advised her of the complaint. Today's investigation consisted of interviews with the administrator and staff, record review, and a physical plant inspection. Staff pushed resident: In regards to the allegation, it was alleged that on or around 09/13/23, Staff 1 (S1) pushed Resident 1 (R1). R1 had to use a wall for support and then lunged at S1. Interviews with the administrator and staff reveal that in the late night on or around 09/13/23, R1 was becoming agitated, and knocking on the doors of the other residents. S1 tried to intervene and stop R1 from doing so, but during the course of their intervention, R1 was becoming aggressive towards S1 prompting S1 to move R1 aside. In addition, S1 stated they never put their hands on R1. Review of facility surviellance reveal that S1's arm was raised, and forearm made Substantiated contact with R1s body, causing R1 to lose balance and lean back against the wall. Additional interviews were held, and there was no reports of any injuries sustained to R1. Review of facility files reveal that S1 received training in Intervention on Aggression, Positive Resident Communication, and Harassment. Although S1 received training with intervention on resident aggression, surveillance video confirms that that S1 made physical contact with R1, causing R1 to lose their balance. Therefore, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised and appeal rights given.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 31-AS-20231019092238

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 25, 2023

Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following: To be accorded dignity in their personal relationships with staff, residents and other persons. This requirement was not met as evidenced by: LPAs received surviellance of an incident that occurred on or around 09/13/23, which reveals S1 pushing or making contact with R1, causing R1 to lose balance. This poses an immediate health and safety risk of the resident.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: As POC, administrator will hold training to address this section of the regulation. As proof training is held, documentation with training log is due to the licensing agency by November 1, 2023.