197603385-10-11-2024-28-AS-TVAO-DBCU5V-20241125141717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 10/10/2024
Date Signed: 10/11/2024 08:34:18 AM

Substantiated

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
10/03/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241003113403

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: 96	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Assistant Administrator Tannya Quezada		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Licensee did not provide adequate notice of fee increase to residents.
Licensee did not abide by the terms and conditions of resident's admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/10/2024 regarding the above allegations. LPA Ramirez was greeted by Assistant Administrator- Tannya Quezada and Director- Zara Poghosyan. LPA Ramirez explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 2 interviews (S1 – S2), Interview of Resident#1 (R1), copies of R1's Admission Agreement, Emgernecy and Identification Information, Physician's Report, Notice of adjustments to rates dated 10/01/2024, Recind notice of adjustments to rates dated 10/10/2024, and physical plant tour.

See 9099-C for continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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-20241003113403

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: 10/10/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Licensee did not provide adequate notice of fee increase to residents – It is alleged the licensee did not provide R1 with adequate notice of fee increase. On 10/01/2024, R1 was given a notice of rate increase based on level of care required and would be effective 11/01/2024. According to the notice, staff will be conducting assessments the week of 10/21/2024, and R1’s new rate will be based on new assessment conducted. Per Title 22, Division 6, Chapter 8, Article 09. Resident Records- 87507(4) Admission Agreement- Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. Licensee did not provide R1 with adequate notice of rate increase. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Licensee did not abide by the terms and conditions of resident's admission agreement - It is alleged the licensee did not abide by R1’s admission agreement. During records review, LPA Ramirez observed R1’s original admission agreement signed by R1 and a facility representative, on 11/03/2021. Per the facility admission agreement, page 4- Section 8. Rate Change- A. “The Agreement must inform the resident of the conditions under which rates may be increased and provide no less than 60 days prior written notice to the resident or the resident’s responsible person.” On 10/01/2024, Licensee issued a notice of rate increase to R1, which did not adhere to R1’s admission agreement. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) violation was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241003113403

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/17/2024 Section Cited CCR 87507(g)(4)	1 2 3 4 5 6 7	87507 Admission Agreements (g) Admission agreements shall specify the following:(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is	1 2 3 4 5 6 7	Licensee will recind prior notice dated 10/01/24 and retrain staff on regulation 87507(4). During visit, Licensee drafted notice to recind. This will clear part of POC. Retraining of staff will be due by 10/17/24. Proof of retraining must be sent via email.
	8 9 10 11 12 13 14	notified of SSI/SSP rate changes. This requirement was not met as evidenced by: Licensee issued notice of rate increase to R1 that was to take effect 11/01/2024. Notice was issued to R1 0n 10/01/24.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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