197603385-3-20-2024-28-AS-WSHO-D59L5J-20240514082710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:14:08 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
03/15/2024 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240315165606

FACILITY NAME:	COMMONWEALTH ROYALE GUEST HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR:	ANNA REMPEL		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	99	CENSUS: 91	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anna Rempel		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff mismanaged resident’s medication.
Staff does not meet resident’s dietary needs.

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 allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 1-9 (R1-9). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-9's facility files, R1-9's medications and Medication Administration Records (MARs), and S1-3 files. LPA collected copies of R1's MARs for February 2024 and March 2024 and other documents pertinent to the complaint investigation including facility menus. LPA conducted a tour of the facility inside and out, the tour included the observations and inspection of the lobby, dining room, medication room, kitchen and food storage. LPA additionally conducted a phone call with R1's Home Health Agency.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20240315165606

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: 03/20/2024

NARRATIVE

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Investigation revealed the following: Staff mismanaged resident’s medication, it is alleged that on 03/14/24, R1 was injected with another resident's medication. R1 allegedly receives medication from a blue pen and was given medication from an orange pen, which belongs to another resident. R1 did not realize until the injection was administered that it was the incorrect colored pen. R1 reported the incident to their nurse but was told by nurse that there was not an orange pen. R1 did not exhibit any side effects and refused to get checked. Interview conducted with Administrator Anna Rempel revealed that facility staff do not administer any injections to facility residents. She stated that facility staff properly administer resident medications at their appropriate prescribed times on a daily basis as well as properly document on resident medication administrator on each resident's MARs. Administrator stated that R1 is seen by a Home Health nurse who comes in once a day to administer their medication. She stated that R1 did report the incident to her and that she spoke to the nurse who stated that a mistake was not made. She stated that R1's vitals were immediately taken and there was no concern noted as well as R1 was observed and no side effects were noted. Interviews conducted with S1-3 revealed that they administer and give residents their medications daily as prescribed by the doctor. They stated that facility staff do not administer injections to any resident and stated that home health nurses come in to administer injections for certain residents. Interviews with 8 out of 9 clients revealed that they get their medications on time everyday and that staff make sure that they take their medications. 4 residents stated that a home health agency comes in to see them either once or twice a day to administer injections. They stated that facility staff do not administer injections to them. LPA interviewed Home Health nurse who denied that R1 was given another resident's medication. Home Health Agency nurse stated that R1 is the only resident at the facility seen by the nurse and that there were no mistakes made with the resident's medication on 03/14/24 or any other day. Home Health Agency nurse stated that R1 is seen once a day for medication administration. LPA review of R1-9s MARs revealed that medications are appropriately administered to residents. R1 stated that the incident only occurred once and that it was a home health nurse who made the alleged mistake and not a staff at the facility. R1 stated that they did not feel any unusual side effects after the alleged medication mistake occurred. Based on interviews conducted with facility staff, facility residents, and LPA review of documents there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff do not ensure special diet plans are followed for residents in care, it is alleged that the facility does not serve food to meet resident's dietary needs. Interviews conducted with facility staff revealed that the food that is served to residents does meets all residents dietary needs and stated that all

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240315165606

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: 03/20/2024

NARRATIVE

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servings include grains, protein, fruits and vegetables. Administrator stated that the menu is reviewed and approved by a registered dietician every month. The dietician reviews the menus to ensure that the meals that the facility is serving to residents that follow a special diet are meeting their daily dietary needs as well as the needs of all residents in care. Administrator stated that food is ordered twice a week for facility to ensure that the facility has a sufficient amount of food supply for all residents in care. Interviews conducted with 8 out of 9 residents revealed that they are satisfied with the food service provided at the facility. 8 out of 9 residents stated that the food is healthy and satisfying, they are served different food options and if they do not want what is on the menu they can request a different meal option. 3 residents who were interviewed stated that they follow a special diet due to a health condition and they stated that they are satisfied with the meals that are served at the facility and stated that all meals served are healthy, well balanced and meet their dietary needs and the facility provides healthy alternatives as well as sugar free options and items such as sugar free substitutes. 1 resident stated that they are not served meals that meet their dietary need and they are forced to eat what is served. LPA toured the facility kitchen and cafeteria and observed facility menu and residents having their lunch. LPA observed the lunch being served to be well balanced with a selection of fruits and vegetables. LPA observed that the daily menu is posted and reflects what will be served for that day and also observed that there was an adequate supply of food which consisted of 2-day perishables and 7-day non-perishables. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation.

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. A copy of the report was provided to Assistant Administrator Anna Rempel.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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