107203215-3-19-2021-24-AS-MHON-BZFV6N-20210325160950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203215
Report Date: 03/19/2021
Date Signed: 03/19/2021 02:36:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2021 and conducted by Evaluator Alexandria Walton

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210302092144

FACILITY NAME:	ROYAL CARE		FACILITY NUMBER:	107203215
ADMINISTRATOR:	RIGON, RUDY G.		FACILITY TYPE:	740
ADDRESS:	2768 PURVIS AVE.		TELEPHONE:	(559) 324-8792
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 3	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Administrator, Aurora Rigon		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff locked resident in bedroom.

INVESTIGATION FINDINGS:

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On 3/19/2021, Licensing Program Analyst (LPA) A. Walton contacted Administrator, Aurora Rigon to deliver findngs on the above allegation via telephone due to COVID-19 and precautionary measures. LPA introduced self and stated the purpose of the call with Administrator.

LPA conducted an interview with Administrator. During the interview, Adminstrator admitted to locking R1 in the bedroom due to R1's behavior.

Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation: Staff locked resident in bedroom, is SUBSTANTIATED.

Continued to LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210302092144

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
	VISIT DATE: 03/19/2021

NARRATIVE

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A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1.

An exit interview was conducted and a Plan of Correction was developed and reviewed with Administrator. A copy of this report and Appeal Right were provided to Administrator, Aurora Rigon via email and an electronic read receipt confirms receiving these documents.

Facility Representative signature on file.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210302092144

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/22/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room... by day or night	1 2 3 4 5 6 7	Administrator removed the lock from R1's door and submitted evidence to the Fresno CCL office. POC Cleared during visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on admission from Administrator, R1 was locked in a bedroom, due to R1's behavior. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	Administrator agreed that staff will be trained on requirements of Personal Rights of Residents in all facilities. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 4/19/2021.
	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.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC9099 (FAS) - (06/04)

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