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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606562
Report Date: 11/15/2021
Date Signed: 11/15/2021 01:19:18 PM



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
11/09/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20211109163557
FACILITY NAME:ROYALTY GUEST HOME, INC.FACILITY NUMBER:
197606562
ADMINISTRATOR:ELENA ANGUSTIAFACILITY TYPE:
740
ADDRESS:20609 BRYANT STREETTELEPHONE:
(818) 727-1741
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
11/15/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elena Angustia TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility is not clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit.

It is alleged that the facility is not clean and has had an issue with rodents. LPA conducted a physical plant walk through of the facility approximately 9:50am-10:15am. During the physical plant walk through LPA did observe some clutter in the living room area. LPA observed the kitchen to be cluttered with a lot of debris that needed to be cleaned up. During the walkt through LPA observed some roaches in the kitchen area. LPA conducted an interview with the administrator who admitted that there has been an issue with roaches and that she has had a pest control company come to service the facility. Based on the information obtained through interviews and observation this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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
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
11/09/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20211109163557

FACILITY NAME:ROYALTY GUEST HOME, INC.FACILITY NUMBER:
197606562
ADMINISTRATOR:ELENA ANGUSTIAFACILITY TYPE:
740
ADDRESS:20609 BRYANT STREETTELEPHONE:
(818) 727-1741
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
11/15/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elena Angustia TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Facility staff not answering calls or returning messages
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit.

It is alleged that the facility doesn't answer the facility telephone and does not return messages. Prior to coming to the facility today LPA called the facility to speak about Covid-19 and facility staff did answer the telephone. LPA also called some responsible parties of the residents in the facilities to do interviews with them from approximately 11:45-12:15pm. Information from interviews reveal that the facility does answer the phone and return messages in a prompt matter. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211109163557
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: ROYALTY GUEST HOME, INC.
FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Administrator will have kitchen and living room clean with pictures submitted to LPA for proof by poc due date. Administrator gave LPA copy of pest control receipts during visit.
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Based on interviews and observation LPA observed the facility to have clutter and debris in the living room area and kitchen area. Administrator stated facility did have an issue with roaches which could pose a potential health and safety risk to residents in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3