191502216-4-4-2024-28-AS-DSIS-D5CPHM-20240517112006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191502216
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:24:50 PM

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
03/26/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240326115044

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: 74	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Tony Agoncillo - Health Services Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not provide adequate food service to residents.
Staff do not ensure resident is bathed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day complaint visit regarding the above allegations. LPA met with Tony Agoncillo, Health Services Administrator and explained the purpose of the visit.

The investigation consisted of the following: LPA toured the facility's building that provides accommodation for the Assisted Living and Skilled Nursing residents. LPA obtained copies of the Staff & Resident Rosters (AL), R1 & R2’s files such as: Functional Capability Assessment, Appraisal/Needs and Services Plan, Physician’s Report, Admission Agreement, Care Plan and copy of residents shower schedule. LPA also obtained the Weekly menu, Meal schedule, Caregivers assignment sheets, Caregivers schedule and Charting notes. LPA conducted interviews with Staff #1 (S1) - Staff #4 (S4) and Resident #3 (R3) - Resident #10 (R10). LPA attempted to interview Resident #1 (R1)-Resident #2 (R2), but unsuccessful as R1 was in SNF being treated, and R2 was asleep. Staff #4 (S4) was off for the day, and LPA's attempt to do phone interview was unsuccessful due to S4 did not answer and voicemail full. Additionally, Staff #6 (S6) was away, therefore not interviewed. ******CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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 2

Control Number 28-AS-20240326115044

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: 04/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Investigation revealed the following:

In regards to allegation: “Staff do not provide adequate food service to residents.” It is alleged that staff sleep during shift and would not wake up to feed the residents breakfast or lunch nor help and feed the residents who need assistance with feeding. Interviews conducted with (5) out of (5) staff denied the allegation. Staff stated that they provide 3 meals a day and the residents are being fed on time. Staff stated that they never heard or witnessed any caregivers failed to provide meals to the residents. S1-S2 stated that they have zero tolerance about staff sleeping on the job and will be automatically written up. S2 indicated that caregivers in the Home Care Dept. provide companionship and additional support to residents who requested the service. Interviewed residents denied the allegation and stated that they eat their meals on time. Some residents stated that their caregivers assist them with feeding. During the visit, LPA observed residents eating lunch in the dining area and in the hallway, there was a cart filled with food trays being delivered to the residents rooms. LPA reviewed R1's charting notes and observed that S5 assisted R1 with feeding during her shift. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to allegation: “Staff do not ensure resident is bathed.” It is alleged that the resident was supposed to get a shower, but staff didn’t do it. Staff interviewed denied the allegation and stated that they never heard this type of complaint. Staff indicated that residents who require shower assistance are accommodated according to their scheduled shower days. Staff stated that residents are given showers either daily or every other day depending on what the resident wants. S2 stated that CNAs are responsible with showering the residents, but caregivers may assist depending on the resident's condition. Interviewed residents denied the allegation. Some residents stated that they take a shower on schedule and get assistance with showering if they ask. LPA reviewed the shower schedule which showed the list of residents who are in need of shower assistance and on which days of the week the services are provided.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held and a copy of this report was provided to Tony Agoncillo, Health Services Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2