191502216-6-19-2020-28-AS-WSHO-BQV3YG-20200623183956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191502216
Report Date: 02/05/2020
Date Signed: 06/19/2020 11:31:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2019 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20190424174457

FACILITY NAME:	ROYAL OAKS		FACILITY NUMBER:	191502216
ADMINISTRATOR:	SALIERNO, ROBERT		FACILITY TYPE:	741
ADDRESS:	1763 ROYAL OAKS DRIVE		TELEPHONE:	(626) 359-9371
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	250	CENSUS: 24	DATE:	02/05/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Health Services Administrator / Meg Pierce		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained fracture during unwitnessed fall.

INVESTIGATION FINDINGS:

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***This is the second amended report which superceeds the original report dated 2/5/20. The purpose of this report is to correct the name of the Investigator listed on this report. The name will be corrected to reflect Robert Kujawa as the Investigator. The findings on this complaint investigation remain unchanged.***

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the investigation conducted by Investigator / Robert Kujawa. Upon arriving at the facility, LPA met with Health Services Administrator / Meg Pierce who assisted with the visit. The allegation listed on this complaint states, "Resident sustained fracture during unwitnessed fall".

Prior visits were conducted at this facility on 4/26/19 and 7/25/19 in reference to the allegation listed above. During the course of the investigation, interviews were conducted with various persons to include the
Health Services Administrator, Power of Attorney (POA) for Resident #1 (R1), Family member of R1, Director of Wellness / Stephanie Coronel and Licensed Vocational Nurse (LVN) / Ursula Pugrad. An interview was not

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2020

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 28-AS-20190424174457

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS	FACILITY NUMBER: 191502216
	VISIT DATE: 02/05/2020

NARRATIVE

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conducted of R1 as R1 expired on 4/21/19. Also, R1's records were obtained and reviewed from the facility and Methodist Hospital.

The investigation revealed the following;

Allegation: Resident sustained fracture during unwitnessed fall.
Based on interviews conducted and reports reviewed, it was discovered that R1 sustained injuries due to two unwitnessed unforeseen falls. The fall incidents occurred on 4/6/19 and 4/15/19. R1 was not considered a fall hazard at the time of the falls. According to Investigator Kujawa, the facility provided proper treatment to R1 after her falls; observation and medical attention by in house medical staff. The facility saw a need for a higher level of care for R1 and was proactive on the subject and notified the family, requesting a higher level of care and a lowered bed. R1 was transferred to the hospital per the request of her family on 4/19/19 and placed on a Do Not Resuscitate (DNR) order. Prior to the transfer, R1 informed staff that she had no pain or discomfort. Comfort measures were in place. R1 expired on 4/21/19 at 2250 hours, due to natural causes at Methodist Hospital. The cause of death for R1 was noted that R1 had significant physical decline while residing at Royal Oaks. There was no involvement by Law Enforcement in this investigation. Based on the investigation conducted by Investigator Kujawa, no evidence of Neglect/Lack of Supervision was found.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of this report was provided to the Health Services Administrator.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2020

LIC9099 (FAS) - (06/04)

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