197603385-3-30-2022-28-AS-FFIS-CLDUYN-20221121150013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 03/29/2022
Date Signed: 03/30/2022 11:22:13 AM

Substantiated

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
03/23/2022 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220323161630

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: 89	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Anna Rempel		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Facility not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced initial complaint visit at the facility and met with Administrator Anna Rempel and explained the purpose for todays visit.

The investigation consisted of the following: LPA conducted an interviews with the Administrator, residents, and staff, and also requested a copy of the staff and resident roster.

Regarding allegaton: Facility not following COVID-19 guidelines. During the interview with the Administrator Anna Rempel, she informed the LPA that on 03/10/22 the Long Term Care Ombudsman(LTCO) arrived to the facility and did not check in with the staff to be screened prior to conducting a visit in the facility. The Administrator also informed the LPA that she saw the LTCO in dining room which is by the PPE station and facility entrance and asked if they needed any assistance. LPA Wesley observed the sign in station with hand santitizer at the entrance of the facility and the temperature check is taken at the Administrators office which is a See LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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-20220323161630

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: 03/29/2022

NARRATIVE

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few feet away from the sign in station. LPA interviewed random clients and staff and was informed that they are screened and also have temperature checks if they leave and return to the building. Staff are pre screened prior to the start of their workshift.

Based on interviews conducted with the administrator, and observations made the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Appeal rights were given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220323161630

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2022 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving	1 2 3 4 5 6 7	The Administrator will ensure that all facility staff are following California Dept of Public Health and CCLD requirements by conducting an in-service training with the staff on the importance of COVID(infection control) screening to all visitors, staff and residents. Administrator will provide a copy of the sign-in sheet with names of attendees and the training topic to CCL, by the POC due date 04/08/22.
	8 9 10 11 12 13 14	services from the facility or the people of the State of California. This requirement is not met as evidenced by: On 03/10/22, Administraor did not screen the LTCO for covid prior to entering the facility and conducting visits. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
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	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220323161630

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: 03/29/2022

NARRATIVE

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SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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