197603385-8-1-2024-28-AS-TVAO-D7YTYM-20240809150854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:45:14 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
07/10/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240710143743

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: 84	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Zara Poghosyan - Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not distributing resident's medications as prescribed
Staff did not ensure that a resident's medication was centrally stored

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Zara Poghosyan and explained the reason for the visit.

The investigation consisted of the following: On 7/13/24 LPA had obtained copies of staff/resident roster and reviewed medication for 5 residents during an annual visit. On 7/15/24 LPA Flores conducted interviews with 8 residents and 5 staff. LPA reviewed 3 additional residents' medication and collected the following copies: Physician's report dated: 7/3/24, admission agreement dated: 10/28/21, appraisal needs and services plan dated: 10/27/21, identification and emergency information dated 10/28/21, and medication sheets for June and July 2024 for resident #1 (R1). On 8/1/24 LPA obtained copies of Med-Tech training and delivered findings for complaint.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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-20240710143743

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: 08/01/2024

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

The investigation revealed the following: Regarding allegation: Staff are not distributing resident's medications as prescribed. It is alleged resident’s prescribed medications were not given to resident as prescribed. Interviews conducted with residents revealed 6 out of 8 residents stated their medication is provide for each dose as prescribed and have not missed any doses of their medications, 2 out of 8 residents stated they have either missed a dose or their dose was switched from the night dosage to the morning dosage by staff. Interviews with staff revealed medication is provided as prescribed and given to the residents by Med-Techs during each mealtime. Per staff the only time a resident misses a dose of their medication is when the residents refuse to take their medication. During medication review which was conducted on 7/13/24 and 7/15/24, LPA observed medications prescribed available for at least 30 days, the medication matched the medication sheets, and was noted by the Med-Tech on the medication sheet after each dose was provided. File review revealed no additional prescribed medications others than the listed ones in medication sheet for R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not ensure that a resident's medication was centrally stored. It is alleged resident’s medication was "tossed inside of a trash can" and not stored properly. Interviews with residents revealed their medication has not been missing at any time and residents stated the facility staff stored their medication for them and it is available for them. Interviews with staff revealed the medication is stored in the medication room, medication has not been disposed or found in the trash can for any of the residents. R1’s injectable medication was observed stored in the refrigerator during medication review. Per med-techs R1 recently started this medication. Usually, this medication is provided by a resident’s program nurse which is brought by them. However, the pharmacy delivered the medication for R1 to the facility, and it is being stored and provided when the nurse asks. During facility’s tour which was conducted on 7/13/24 LPA did not observed medications in common areas or resident rooms. Med-Techs last training was provided on 7/20/24.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview was conducted with and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2