197603747-9-21-2021-31-AS-EMIR-C9SNB8-20211217091842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603747
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:58:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2021 and conducted by Evaluator Calvin Tsui

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210903113520

FACILITY NAME:	ROYAL GARDEN BOARD & CARE III		FACILITY NUMBER:	197603747
ADMINISTRATOR:	RADA KIGEL		FACILITY TYPE:	740
ADDRESS:	5809 MELVIN AVENUE		TELEPHONE:	(818) 609-7763
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rada Sigal		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff failed to provide adequate supervision, resulting in resident 1(R1) wandering away from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Calvin Tsui and Licensing Program Manager (LPM) Eva Miller conducted a subsequent complaint visit at the facility and met with Gerardo Centeno and Rada Sigal

The complainant alleged that Resident #1 (R-1) left the facility on or about 9/3/21 without the knowledge of the direct care staff on duty. R-1 was delivered to Kaiser Hospital Emergency Room (ER) at approximately 7:00am by a member of the public who happened upon R-1 in the community. Hospital Personnel contacted R-1's daughter who subsequently contacted the Facility Administrator. Staff on duty (S-1) last observed R-1 in the faciltiy at approximately 4:00am on 9/3/21 via a video monitor. S-1 observed that R-1 was not in bed at approximately 4:30am via a video monitor but did enter the room to ascertain R-1's status. S-1 did not determine that R-1 was missing until approximately 6:00am. S-1 reported the missing resident to the Administrator and the two conducted an unsuccessful search of the immediate neighborhood, after which they reported the missing resident to the Los Angeles Police Department (LAPD).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin Tsui	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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 3

Control Number 31-AS-20210903113520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL GARDEN BOARD & CARE III	FACILITY NUMBER: 197603747
	VISIT DATE: 09/21/2021

NARRATIVE

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The Administrator was advised that R-1 had been found at the Kaiser Hospital ER by R-1's daughter via telephone. R-1 was provided with an examination at the ER and subsequently returned to the facility on the same day.

LPA Tsui and LPA Yelena Avetisyan conducted an initial investigative visit at the facility on 9/9/21. A tour of the physical plant was conducted as well as interviews with Staff and the Administrator and a review of facility records for R-1. During the tour of the physical plant the LPA's observed that two of the auditory alarms were not operational. An interview with the daughter of R-1 was conducted via telephone by LPA Tsui and LPM Miller on 9/21/21 at 8:30am.

Based on the content of the interviews conducted on 9/9/21 from 2:00pm and 3:10pm and the interview with the daughter of R-1 on 9/21/21 as well as a tour of the physical plant on 9/9/21, LPA Tsui was able to substantiate the allegation that due to a lack of care and supervision by Direct Care Staff R-1 was able to leave the facility without their knowledge placing R-1 at risk.

Citations issued, appeal rights provided and exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin Tsui	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210903113520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL GARDEN BOARD & CARE III	FACILITY NUMBER: 197603747
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2021 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to ensure all auditory alarms are functional and activated. An additional auditory alarm will be installed to the outside of the exterior door to the room for R-1. At the time of this visit all bedroom exterior doors have functional auditory alarms installed on the inside are functional
	8 9 10 11 12 13 14	Based on the observations of LPA's the alarm on the exit door was inoperable in Rm#6. Staff stated alarm had been in-op for a minimum of 1 week so staff disabled the alarm resulting in an immediate risk to the health & safety of residents in care.	8 9 10 11 12 13 14
Type A 09/21/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to ensure all auditory alarms are functional and activated. An additional auditory alarm will be installed to the outside of the exterior door to the room for R-1. At the time of this visit all bedroom exterior doors have functional auditory alarms installed on the inside are functional. There will be at
	8 9 10 11 12 13 14	Based on observations by LPA's and statements by Staff, R-1 was able to leave the facility without the knowledge of staff on duty indicating insufficient staffing resulting in an immediate risk to the health & safety of residents in care.	8 9 10 11 12 13 14	a minimum one awake staff at night.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin Tsui	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

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