197603385-6-20-2024-28-AS-RORN-D6KNZR-20240625105443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:22:15 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
07/13/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230713121244

FACILITY NAME:	COMMONWEALTH ROYALE GUEST HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR:	KITT, GARY		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	99	CENSUS: 78	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Anna Rempel		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect led to serious hospitalization of resident.
Staff did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Alma Gonzalez conducted unannounced subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 07/17/23, LPA Gonzalez collected copies of Staff and Resident rosters, conducted a tour of entire facility inside and out with Administrator Anna Rempel and observed residents in the facility at the time of the visit. LPA observed the residents to identify any signs of neglect, abuse or other immediate Health and Safety threats. LPA did not observe any immediate Health & Safety concerns during the visit.

The investigation for this complaint was conducted by Investigator Christine Ferris.

(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: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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 3

Control Number 28-AS-20230713121244

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: 06/20/2024

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

During the course of the investigation, Investigator Ferris obtained copies of the following documents pertaining to Resident 1 (R1): Physician’s Report For Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 06/20/23 and 08/09/22, two (2) Unusual Incident/ Injury Reports (LIC624) dated 07/10/23 and 04/21/23, Resident Appraisal (LIC603A), Preplacement Appraisal Information (LIC603), Facility Communication Notes, Identification and Emergency Information, Appraisal/ Needs and Services Plan (LIC625) dated 05/01/19, Kaiser Permanente Hospital Records, and Los Angeles Fire Department Care Report dated 07/07/24. Investigator Ferris interviewed Facility Administrator Anna Rempel, facility staff (S1-5), facility Residents 1-2 (R1-2), R1 Family Member (R1 FM1) and Gateways Conditional Release Program (ConRep) Clinical Director (W1).

The investigation revealed the following: Regarding allegation of, Staff neglect led to serious hospitalization of resident, during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, reviewed hospital records which revealed that R1 was hospitalized due to an ongoing medical diagnosis and complications that resulted from it. Hospital Records revealed that R1’s hospitalization was not a result of neglect/ lack of supervision. Investigator Ferris stated that there was insufficient evidence to support the allegation of Neglect/ Lack of Supervision led to R1’s hospitalization. Based on the investigation and supporting information obtained, this allegation is not corroborated.

For allegation, Staff did not seek timely medical attention for resident, during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, interviewed facility administrator and S1-5 and their statements revealed that R1 was provided adequate and timely care and they were unaware that R1 had recently fell. Administrator stated that R1 had one fall on 04/20/23 while they were outside of the facility and that there were no reports of R1 falling since then. Administrator stated that R1 will let staff know when they need to see or speak to their doctors and had not requested to go to the hospital. Administrator stated that R1 was hospitalized on 07/07/23 due to observation of resident being weak. Interview with R2 who is R1’s roommate revealed that they did not see R1 fall or see R1 on the floor and only heard a noise that sounded as if R1 had fallen. R2 stated that R1 did not mention they had fallen, and that staff checked on R1 and then sent R1 to the hospital. R1 stated that they did not recall what happened prior to their hospitalization and did not recall falling off the toilet or anywhere else. R1 stated that R1 FM1 told them that they had fallen. R1 stated that they like the facility but that R1 FM1 does not like the facility as they believe that R1 is not getting adequate care. R1 stated that R1 FM1 has not visited them at the facility as they live out of state. R1 stated that staff would send them to the hospital if they had a fall. R1 stated that they do not have any concerns with the facility and that staff provided a good level of care and supervision. R1

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230713121244

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: 06/20/2024

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

additionally stated that they were treated well at the facility, they were never mistreated or neglected by facility staff. R1 stated that staff had never denied them medical attention when needed or requested. R1 stated that they would return to the facility when possible and felt that the facility was safe for them and other residents. Based on interviews conducted with facility staff and R1-2 there is insufficient evidence to support the allegation, this allegation is not corroborated.

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 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: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3