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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 04/11/2022
Date Signed: 04/11/2022 04:50:32 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
04/04/2022 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220404150645
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: 87DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Anna RempelTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility won't return resident's property
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 Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Anna Rempel, Staff 1-2 (S1-2) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information LIC601 dated 8/4/21, Preplacement Appraisal Information LIC 603 dated 8/2/21, Resident Appraisal LIC603A dated 8/4/21, Client/ Resident Personal Property and Valuables, Facility Note regarding R1, Telecare Transportation Request dated 3/3/22, Note signed by R1's Family Member (R1 FM) regarding personal belongings dated 3/26/22, and Physician's Report For Residential Care Facilities for the Elderly LIC 602A dated 10/8/21.

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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-20220404150645
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: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 04/11/2022
NARRATIVE
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LPA conducted a tour of facility which included observations of common areas, lobby, dining room, kitchen and random resident rooms which included R1's previous room. LPA also attempted to contact R1 and R1's FM but was not able to establish contact with either one. LPA conducted a phone interview with Gateways Forensic Community Treatment Program (FCTP) representative Adriana Collins.

Investigation revealed the following: Regarding allegation, Facility won't return resident's property, it is alleged that a previous resident has tried to get their property back and keeps trying to call the facility to get their property back but a facility staff allegedly hangs up on the previous resident when they call. Previous resident states that they left behind 400 cough drops, an iron, space heater, radio, clothes and shoes. It is also alleged that the facility made the previous resident donate their refrigerator and TV before leaving the facility. Interview with Administrator Anna Rempel revealed that when R1 left the facility they took all their belongings. She stated Gateways FCTP representatives who transported R1 to their new facility, picked up the resident and all their belongings including all medications. She stated that on 3/26/22 R1's FM came to the facility and collected R1's paperwork and a binder with additional paperwork that was left behind by R1. She stated that R1 and R1's FM both signed that they took/ picked up belongings and medications. Administrator Rempel denies hanging up on R1 when they called to inquire about their belongings and stated that she just told R1 that there are no items or belongings that belong to the resident at the facility. She stated that she instructed R1 to call Gateways FCTP as when they assisted R1 with the move they also assisted them with their belongings. Administrator denies that R1 left any items such as 400 cough drops, an iron, space heater, radio, clothes and shoes. Administrator also denies that any facility staff allegedly made R1 donate their refrigerator and TV. Interviews with S1-2 revealed that R1 took all their belongings when they left the facility and stated that the resident did not leave behind a refrigerator and a TV. Interview with R8, who was R1's roommate, revealed that R1 took all their belongings and did not leave anything behind. R8 stated that R1 did not leave a refrigerator, TV, 400 cough drops, an iron, space heater, radio, clothes or shoes. Interviews conducted with 6 out of 8 facility residents revealed that they are satisfied with all services that they receive at the facility and stated that they have not had any issues or concerns with the facility regarding their personal belongings/ property. 1 of 8 residents declined to be interviewed. LPA attempted to contact R1 but was not able to reach previous resident. LPA also attempted to contact R1's FM but the phone number that was provided was not a working phone number. LPA toured R1's previous room and did not observe items such as 400 cough drops, an iron, space heater, radio, or a refrigerator that belonged to R1.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220404150645
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: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 04/11/2022
NARRATIVE
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LPA did observe a TV that belongs to R8. LPA toured storage area and did not observe any of the items that were reportedly left behind by R1. LPA reviewed a signed note from R1 stating that belongings and medications were picked up on 3/4/22. LPA also reviewed a note signed by R1's FM stating that belongings were picked up on 3/26/22. The signed note from R1's FM included a picture of their CA Driver License. LPA additionally spoke with Gateways FCTP representative Adriana Collins who stated that R1 took all their belongings when they were transported to their new faciltiy.Based on interviews conducted with facility staff, facility residents, FCTP representative, LPA observations, and LPA review of records, 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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3