191502216-10-6-2023-28-AS-FFIS-CWM5QR-20231014200955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191502216
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:58:55 PM

Unsubstantiated

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
09/15/2022 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220915141701

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: 174	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Director of Wellness Eusebio (Sev) Tiendia		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not respond to resident's call for assistance in a timely manner.
Staff did not provide medical assistance to resident in a timely manner.
Food services are inadequate.
Staff do not ensure resident's special diet is followed.
Staff did not safeguard resident's personal belongings.
Staff threatened resident.
Staff placed unsafe equipment in resident's room.
Facility is in disrepair.
Facility did not follow Covid-19 testing protocols.

INVESTIGATION FINDINGS:

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** This report supersedes report dated 8/24/23. LPA Villalobos gathered additional information and conducted further interviews regarding the allegations above. There are no changes to the findings**

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Jill Crowell (Director of Resident Services) and explained the purpose of the visit. A short time later Eusebio (Sev) Tiendia (Director of Wellness) also met with LPA and assisted with the complaint investigation.

During the initial visit on 09/21/22, LPA Kruz obtained a copy of the Staff/Resident rosters, Admission Agreement (R#1) and Charge Statement. LPA also toured the facility with Jill Crowell, interviewed Staff #1 and #2 (S1-S2) in the conference room and interviewed Resident #1 (R#1) in their living unit. During the second visit on 8/24/23, LPA Kruz obtained a copy of the Staff/Resident rosters and interviewed Residents #2 to #10 (R2-R10) in the office. (Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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 5

Control Number 28-AS-20220915141701

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: 10/06/2023

NARRATIVE

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On todays visit, LPA Villalobos toured the physical plant, interviewed staff #1-#7 (S1-S7), Collected work order report for R1's room, incident report for R1 dated 4/28/22, and R1's facesheet with physicians report. The investigation revealed the following:

In regards to the allegation "Staff did not respond to resident's call for assistance in a timely manner." it was alleged R1 pulled the emergency cord in their room and no assistance arrived until 17 hours later. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Interview with staff stated that R1 did have an unwitnessed fall in their room on 4/28/22. R1 is an independent living resident of the facility. Interviews state there are no signal or pull cords on 4/28/22 for R1's room. Interviews with staff state that there is a sensor that signals staff when a resident in the independent living rooms does not get out of bed by 10am. When they are alerted, staff will call the room to check on the resident and if there is no answer, they conduct a check. On 4/28/23 this specific signal came for R1's room and staff went to check on R1 and that is when they were observed on the floor by their bedside. There was no pull cord used by R1 and as R1 is an independent living resident, there are no continuous monitoring of residents location throughout the day other then the previous mentioned 10am signal. Interviews with other residents show that staff respond timely to emergency pull cords and there are no issues regarding staff timely responses. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

In regards to the allegation "Staff did not provide medical assistance to resident in a timely manner" it was alleged that R1 fell in their room and was not provided medical assistance in a timely manner. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. File review shows that R1 had a fall on 4/28/22 and was assisted by staff. R1 was transported to the hospital and returned to the facilities skilled nursing department. Interviews show that R1 was assisted immediately after being found on the floor by their bedside on 4/28/22. Resident interviews indicate medical assistance is provided by staff when needed. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

(Continued on LIC 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20220915141701

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: 10/06/2023

NARRATIVE

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In regards to the allegation "Food services are inadequate." it was alleged that the food is dry and given in small portions. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. LPA toured the kitchen and observed all food are of good quality. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days is maintained. Interviews with Staff indicate food service is adequate. Interviews with (9) of (10) Residents indicate food service is adequate and different food choices are available. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

In regards to the allegation "Staff do not ensure resident's special diet is followed." it was alleged that staff do not follow the list of foods R1 can eat. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Per allegation details, it was alleged the facility is not providing Resident #1 with a special diet. Investigation revealed Resident #1 does not require a special diet and there is no physician's order for a special diet. Interviews with staff indicate residents requiring a special diet is provided with meals based on physician's order. LPA Villalobos reviewed R1's file and did not observe a physicians order for special diet. LPA observed a hand written letter by R1 of R1's preferred meals and methods of cooking their meals. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

In regards to the allegation "Staff did not safeguard resident's personal belongings" it was alleged that staff damaged R1's personal item and did not correct the situation and that medications were missing from their room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews show there was a day when staff damaged one of R1's personal items accidentally while conducting repairs to the living unit. Facility immediately reimbursed Resident #1 for the damaged item. LPA observed and collected documentation showing that R1 was compensated. Interviews show R1 accepted the compensation. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

(Continued on LIC 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220915141701

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: 10/06/2023

NARRATIVE

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In regards to the allegation "Staff threatened resident" it was alleged that S1 threatened R1 to sign documentation of money they were reimbursed. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Staff interviewed denied that S1 ever threatened R1. Interviews with residents does not show staff to speaking to them in a threatening manner or to any other residents. LPA was not provided with proof that S1 threatened R1. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

In regards to the allegation "Staff placed unsafe equipment in resident's room." it was alleged that facility staff placed a dangerous gas powered heater in R1's room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed denied the allegation. Interviews with staff state that there are no gas powered heaters in any rooms or any that are provided to residents. There are small electric powered heaters that can be provided upon request if a resident chooses. No gas heaters were observed throughout the visits. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

In regards to the allegation "Facility is in disrepair." it was alleged that there are multiple leaks and issues with the bathroom in R1's room that staff were not addressing. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegations. Interviews with staff and residents shows that items that need repair are completed in a timely manner. Work orders are completed and assigned dates to staff to complete. LPA observed work orders for leaks and ceiling repairs completed in R1's bathroom between 4/21/22-4/28/22. Residents interviewed stated the facility is always clean and in good repair and if an item is broken, an order is placed and maintenance will repair it right away. LPA's observed the facility to be clean and in good repair during visits. R1 stated that staff do repair the issues when they are informed of them. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

(Continued on LIC 9099-C)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220915141701

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: 10/06/2023

NARRATIVE

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In regards to the allegation "Facility did not follow Covid-19 testing protocols" it was alleged that the facility is supposed to test everyone for covid and never did. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. During the initial visit, Staff checked LPA Kruz's temperature and was provided a Covid-19 questionnaire. Interviews with Staff indicate Covid-19 testing protocols were followed. Interviews with residents also indicated Covid-19 testing protocols were followed. During LPA Villalobos' visit, there are no requirements regarding covid screening. Interviews with staff shows that the only people who are testing for covid 19 at the moment would be someone who has tested positive on their own or anyone who is suspected of having covid due to exposure. Other than that, there is no policy to test residents and staff regularly. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported 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.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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