197603385-8-12-2022-28-AS-RORN-CHUNPK-20220901103828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 08/12/2022
Date Signed: 08/12/2022 01:47:57 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
05/04/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210504154700

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: 88	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Ana Rempel; Administrator		TIME COMPLETED:	02:03 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not ensuring that resident is eating.
Facility is not ensuring that resident is drinking fluids.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Administrator Ana Rempel and explained the reason for the visit.

The investigation consisted of the following: during the initial Televisit conducted on 05/07/21, LPA interviewed the Administrator and obtained copies from Resident #1 (R1) file such as: ID & Emergency Sheet, Physician's Report, Resident Appraisal, and Incident Report. During today's visit, LPA obtained copies of Resident & Staff Rosters and interviewed Staff #1 - Staff#3 and Resident #2 - Resident#8. Resident #1 (R1) was not interviewed as R1 is no longer a resident of the facility.

The investigation revealed the following: in regards to the allegations "facility is not ensuring that resident is eating" and "facility is not ensuring that resident is drinking fluids", it is alleged that R1 has not been eating or drinking water at the facility and has been self-neglecting. R1 moved into the facility on 04/23/21. On 05/06/21, R1 was transported to the hospital for a mental health evaluation. R1 did not return to this facility after her hospitalization. Interviews conducted with staff members denied the allegations. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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 2

Control Number 28-AS-20210504154700

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: 08/12/2022

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

Staff members interviewed indicated water and meals were offered and provided to R1, however R1 had difficulty adjusting to the facility and would sometimes refuse facility services. Facility staff kept R1's Case Manager and Responsible Person aware of R1's situation while at the facility. Interviews conducted with other residents at the facility denied the allegations. Residents interviewed indicated that the facility provides sufficient food and water to meet their needs. Staff members interviewed indicated residents are provided with 3 meals per day along with 2 snacks. Drinking water is also readily available for the residents. LPA toured the facility and observed facility food and water supply to be sufficient for the number of residents in care.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2