197603385-2-4-2025-28-AS-RORN-DFBUBL-20250401152632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:20:21 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
01/29/2025 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250129153136

FACILITY NAME:	COMMONWEALTH ROYALE GUEST HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR:	MAYA MNOYAN		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	99	CENSUS: 92	DATE:	02/04/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Anna Rempel (Administrator) and Zara Poghosyan (Director)		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are not administering resident's medications as prescribed.
Staff are falsifying medication documentation.
Staff did not reorder resident's medications timely.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial visit to investigate the above allegations. LPA met with Anna Rempel (Administrator) and Zara Poghosyan (Director) and discussed the purpose of today’s visit.

During this visit, LPA obtained a copy of the resident and staff rosters, interviewed Resident #1 (R-1) through Resident #8 (R-8), interviewed Staff #1 (S-1) through Staff #4 (S-4), reviewed R-1’s file and obtained relevant documentation and conducted tour of medication room.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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-20250129153136

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: 02/04/2025

NARRATIVE

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Staff are not administering resident's medications as prescribed. It has been alleged that staff are not administering residents’ medications as prescribed. Resident interviews revealed that staff provide them with their prescribed medications daily. Interviewed residents indicated they have not had any issues/concerns regarding this matter. Interviewed residents indicated they have not heard other residents complaining about their medication not being administered. Interviewed staff indicated that they provide residents with their medication as prescribed. Interviewed staff indicated that R-1 tends to refuse to take R-1’s ointment medication which is documented on the back of the Medication Administration Record (MAR). Interviewed staff indicated that R-1 takes R-1’s Ativan and Citalopram daily and has not refused to take these medications. Interviewed staff indicated that C-1’s pharmacy sent extra medication bubble packs (for January 2025) with Ativan and Citalopram and staff were awaiting for the end of the cycle to return them back to the pharmacy. Interviewed staff indicated that R-1 has not complained about not receiving their medication. Interviews do not corroborate this allegation.

Staff are falsifying medication documentation. It has been alleged that R-1’s Medication Administration Record (MAR) had been signed by staff as medication being administered to R-1 when medication was not administered to R-1. Based on record review and interviews conducted with residents and staff, there is no evidence to corroborate this allegation.

Staff did not reorder resident's medications timely: It has been alleged that R-1’s PRN (as needed) and routine medications were all empty and refills had not been requested at the time. Based on record review and interviews conducted with residents and staff, there is no evidence to corroborate this 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 conducted, a copy of the Appeal Rights and this report was provided to Anna Rempel (Administrator).

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC9099 (FAS) - (06/04)

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