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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:13:35 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
09/01/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230901134314
FACILITY NAME:COMMONWEALTH ROYALE GUEST HOMEFACILITY NUMBER:
197603385
ADMINISTRATOR:KITT, GARYFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:99CENSUS: 85DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anna RempelTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not prevent resident from injuring another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Assistant Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 1-8 (R1-8). R9 was not interviewed as resident was not at the facility at the time of the visit. LPA collected copies of Staff and Resident Rosters. LPA reviewed R8-9's facility files and collected copies of documents relevant to the investigation. LPA also collected a copy of Unusual Incident/ Injury Report dated 08/26/23.



(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 2
Control Number 28-AS-20230901134314
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: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 09/07/2023
NARRATIVE
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Investigation revealed the following: Regarding allegation, Facility staff did not prevent resident from injuring another resident, it is alleged that on 08/26/23 a facility resident pulled another resident's hair and also scratched the resident's face. The severity of the injury is unknown, if first aid was administered or if the resident was seen by a doctor. Interviews conducted with Assistant Administrator and S1-3 revealed that on 08/26/23 there was an altercation between R8 and R9. They stated that R8 reported to staff that R9 had pulled their hair. They stated that R8 did not report that R9 had scratched them on their face and also stated that R8 did not have any visible scratches on their face that required first aid or a higher level of medical care. Staff stated that if any resident is hurt and requires first aid, it is immediately administered or if a resident requires higher level of medical care the facility will call 911 and arrange for transportation to a local hospital and/ or urgent care clinic. Assistant Administrator stated that R9 was hospitalized due to verbal threats that they made towards R8 on 08/28/23 when they were talking to their social worker. Administrator stated that she immediately reported the incident to all applicable agencies, including Community Care Licensing Division (CCLD) and she also completed and submitted a Report of Suspected Dependent Adult/ Elder Abuse (SOC 341) to all applicable agencies. Assistant Administrator and S1-3 stated that there are enough staff on schedule at all times to oversee the residents in care and provide adequate care and supervision. They stated that staff immediately respond to any incidents between residents. They stated that the incidents between residents are usually verbal and residents are redirected. Interviews conducted with 8 out of 9 facility residents revealed that they do not have any concerns and stated that they believe there are enough staff on schedule to supervise them. They stated that whenever there are any arguments between residents staff will immediately intervene but for the most part everyone gets along and the facility is calm. R8 stated that R9 only pulled their hair on 08/26/23 and staff immediately intervened and also moved R9 to another room. R8 stated that staff did everything they had to do to keep them safe. R8 stated that they did not have any concerns about the facility or the staffing and is satisfied with the services that they receive. R8 stated that they feel safe now that R9 is not at the facility and is not their roommate anymore.

During the time of the visit, LPA did not observe any altercations between residents and observed that there were enough staff on schedule. LPA reviewed documents and observed that the proper reporting was done by facility staff as well as proper follow up calls made to both involved resident's social workers. LPA additionally reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. Based on statements gathered from interviews conducted with staff, residents and LPA review of documents, 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 held. A copy of the report was provided to Assistant Administrator Anna Rempel.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
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