197603385-7-17-2023-28-AS-RORN-CU3M4K-20230725091650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:36:28 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
08/27/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210827134530

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: 94	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Gary Kitt		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident severely deydrated resulting in hospitalization.
Resident malnourished while in care.
Resident's care needs are not beng met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Gary Kitt and Assistant Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 8/30/21, LPA Gonzalez collected copies of Staff and Resident rosters, reviewed R1's file, and collected copies of documents pertinent to the investigation. LPA also conducted interviews with Administrator Gary Kitt, Assistant Administrator Anna Rempel and R1's doctor by telephone. LPA also conducted a tour of entire facility inside and out with Assistant Administrator Anna Rempel and LPA did not observe any immediate Health & Safety concerns during the visit. On 02/21/23, LPA mailed/ faxed an Investigative Subpoena Duces Tecum to PIH Health Good Samaritan Hospital requesting medical records regarding R1. On 02/27/23, LPA received

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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-20210827134530

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: 07/17/2023

NARRATIVE

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Declaration of Custodian of Medical Records - PIH Health Good Samaritan Hospital stating that there were no medical records for R1. On 04/11/23, LPA contacted Pacific Hospice Care and requested records for R1. On 04/12/23, LPA received R1's records via email from Pacific Hospice Care. On 07/17/23, LPA conducted interviews with Staff 1-3 (S1-3) and Residents 2-9 (R2-9). LPA conducted a phone call to R1 Friend (R1 F). LPA additionally collected copies of Staff and Resident Rosters.

Investigation revealed the following: Regarding allegation, Resident severely dehydrated resulting in hospitalization, it is alleged that a resident of the facility (only last name provided) was dehydrated and unable to make decisions on their own and were gravely disabled. Interviews conducted with facility administrator and Assistant Administrator revealed that R1 was the resident that was hospitalized and that the last name given was not any current resident's name. They stated that R1 is receiving hospice care twice a week. They stated that R1's medical condition was long standing and was getting progressively worse. They stated that when R1 was hospitalized on 8/25/21 they were positive for COVID19 and were experiencing severe symptoms. They denied that R1 was dehydrated. LPA review of hospice records revealed that R1 was seen twice a week and that R1 complained of certain symptoms such as generalized weakness and decrease in appetite due to long standing medical condition. Interview with R1's Doctor revealed that R1 was seen monthly and that R1 was not dehydrated but was only suffering complications in relation to their diagnosis. Interview with R1 F revealed that they did not have any concerns about the facility or the care that R1 received at the facility. R1 was not interviewed due to R1 not being a resident of the facility. Based on interviews conducted with facility staff, resident's doctor, resident friend, and LPA record review, there was not enough supportive evidence to concur with the reported allegation

For allegation, Resident malnourished while in care, it is alleged that a resident of the facility (only last name provided) was malnourished and unable to make decisions on their own and were gravely disabled. Interviews conducted with facility administrator and Assistant Administrator revealed that R1 was the resident that was hospitalized and that the last name given was not any current resident's name. They stated that R1 is receiving hospice care twice a week. They stated that R1's medical condition was long standing and was getting progressively worse. They stated that when R1 was hospitalized on 8/25/21 they were positive for COVID19 and were experiencing severe symptoms. They denied that R1 was malnourished and stated that R1 was frail due to their medical condition. LPA review of hospice records revealed that R1 was seen twice a week and that R1 complained of certain symptoms such as generalized weakness and decrease in appetite

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210827134530

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: 07/17/2023

NARRATIVE

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due to long standing medical condition. Interview with R1's Doctor revealed that R1 was seen monthly and that R1 was not malnourished but was only suffering complications in relation to their diagnosis. R1's doctor also stated that R1 was frail and was underweight for years and they were better living at the facility. R1's doctor also stated that the facility staff immediately notified them when R1 was hospitalized. Interview with R1 F revealed that they did not have any concerns about the facility or the care that R1 received at the facility. R1 was not interviewed due to R1 not being a resident of the facility. Based on interviews conducted with facility staff, resident's doctor, resident friend, and LPA record review, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Resident's care needs are not being met, it is alleged that facility staff did not know condition of a resident of the facility (only last name provided). It is also alleged that facility staff stated that resident is able to make their own decisions although they have a history of Major Neurocognitive Disorder and staff and resident's physician state that the resident is able to make their own decisions. Interviews conducted with facility administrator and Assistant Administrator revealed that R1 was the resident that was hospitalized and that the last name given was not any current resident's name. They stated that R1 is receiving hospice care twice a week. They stated that R1's medical condition was long standing and was getting progressively worse. They stated that when R1 was hospitalized on 8/25/21 they were positive for COVID19 and were experiencing severe symptoms. They stated that R1's needs were being met. LPA review of hospice records revealed that R1 was seen twice a week and that R1 complained of certain symptoms such as generalized weakness and decrease in appetite due to long standing medical condition. Interview with R1's Doctor revealed that R1 was seen monthly and that R1's needs were being met by the facility. R1's doctor stated that R1 was frail and they were better living at the facility. R1's doctor also stated that the facility staff immediately notified them when R1 was hospitalized. Interview with R1 F revealed that they did not have any concerns about the facility or the care that R1 received at the facility. R1 was not interviewed due to R1 not being a resident of the facility. LPA reviewed R1's Physician Report dated 10/7/20 and observed that the report indicates that R1 is not diagnosed with Major Neurocognitive Disorder and continues to maintain the ability to follow instructions and communicate needs. Based on interviews conducted with facility staff, resident's doctor, resident friend, and LPA record review, there was not enough supportive evidence to concur with the reported 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 held. A copy of the report was provided to Assistant Administrator Anna Rempel.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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