191502216-9-18-2023-28-AS-TVAO-CVSQPV-20230918122118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191502216
Report Date: 09/15/2023
Date Signed: 09/18/2023 10:25:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/11/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230811161004

FACILITY NAME:	ROYAL OAKS		FACILITY NUMBER:	191502216
ADMINISTRATOR:	ANDREW M SMITH		FACILITY TYPE:	741
ADDRESS:	1763 ROYAL OAKS DRIVE		TELEPHONE:	(626) 359-9371
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	250	CENSUS: 152	DATE:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	04:01 PM
MET WITH:	Andrew Smith		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care of the facility.
Staff did not respond to resident's call for assistance.
Staff are not meeting resident's hygiene needs.

INVESTIGATION FINDINGS:

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*This is a corrected version of initial 10-day complaint investigation dated 8/15/23. No changes to finding.*
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/15/23 regarding the above allegations. LPA Ramirez was met by Administrator Andrew Smith and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1 interview (R1 ), Copies of Resident #1 (R1): Profile Face Sheet, Interdisciplinary Notes dated 7/31/23 and 8/1/23, facility staff response notes for the month of July 2023, Doctor’s Order Sheet dated 5/18/23 through 7/25/23, Pomona Valley Hospital History and Physical Report dated 8/1/23, Addendum to Care and Residence Agreement dated 10/4/22, Preplacement Appraisal Information dated 7/26/20, Physician’s Report dated 5/20/20, Device Activity Reports dated 7/31/23 and 8/1/23, Special Incident Reports (SIR) for R1, and physical plant tour.
See 9099-C for continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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-20230811161004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS	FACILITY NUMBER: 191502216
	VISIT DATE: 09/15/2023

NARRATIVE

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The investigation revealed the following. Regarding Allegation(s): Resident sustained multiple pressure injuries while in care of the facility- It is alleged R1 sustained multiple injuries while in care of the facility. R1 was admitted into the independent living unit of the facility on 8/18/20. Records review revealed that R1 sustained three (3) unwitnessed falls in R1 accommodation from June 2023 through July 2023. On 6/3/23, staff reported R1’s had an unwitnessed fall, and no injuries were noted. On 6/28/23, staff reported R1’s unwitnessed fall, and no injuries were noted. On 7/23/23, staff reported R1’s unwitnessed fall and injuries were noted. Doctor’s Order Sheet signed and dated by R1’s physician, indicates R1 is okay to return to accommodation. LPA Ramirez reviewed Pomona Valley Hospital notes dated 8/1/23 and no observations of pressure injuries were noted on history of present illness. LPA Ramirez could not locate any documentation or staff interviews indicating R1 suffered from any pressure injuries prior to unwitnessed falls. Four (4) out of four (4) staff interviewed deny this allegation. R1 denied this allegation however, R1 could not articulate what a "pressure injury" is or how such injury can occur. 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.

Staff did not respond to resident's call for assistance- It is alleged that facility staff did not respond to R1’s accommodation after R1 pushed panic button. On or around 8/1/23 at 10:14 am, R1 was discovered by staff wedged in between side rail and bed. According to staff interviewed, R1 was wearing alert pendant when R1 was discovered on 8/1/23. Per S1 interview, R1 was wedged in an angle that prohibited R1 from accessing pendant around neck. On 7/31/23 at approximately 9:51 pm, R1 pushed alert pendant. At 10pm, staff responded and noted R1 sitting on floor and indicated that R1 fell. R1 stated that no injuries and was assisted back to bed. On 8/15/23, LPA Ramirez toured R1’s accommodation and tested emergency pull cord in bathroom. Facility staff responded within 1 minute by calling R1’d bedside phone. LPA Ramirez reviewed facility Device Activities Report dated 8/1/23 and could not locate a request for assistance by R1. Facility staff did respond to a request for assistance on 8/1/23 to R1’s accommodation due to staff finding R1 wedged in between bed and half rail. Four (4) out of four (4) staff interviewed deny this allegation. Interview with R1 revealed, R1 recalled pushing pendant but stated staff did not arrive. R1 later stated during interview that R1 could not reach pendant due to left arm being wedged in between bed and rail. 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.

See 9099-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230811161004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS	FACILITY NUMBER: 191502216
	VISIT DATE: 09/15/2023

NARRATIVE

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Staff are not meeting resident's hygiene needs- It is alleged R1 appeared disheveled and lacked proper hygiene. Physician’s report dated 5/20/20 indicates R1 is ambulatory and does not require bathing/grooming assistance. On 10/14/22, R1 signed Addendum to Care and Residence Agreement that provides additional care to R1 with personal care, escort, housekeeping, errands, pet care, and additional services at R1’s request. LPA Ramirez reviewed staff response notes for the month of July 2023. LPA Ramirez counted at least eleven (11) documented instances of R1 requesting staff assist with bathing and staff responding to R1’s request. Four (4) out of four (4) staff interviewed deny this allegation. 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.

No deficiencies are being cited during visit. Exit interview was conducted and a copy of this report was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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