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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607361
Report Date: 06/03/2026
Date Signed: 06/04/2026 06:08:15 PM

Substantiated


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
12/03/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20251203143852
FACILITY NAME:ROYAL PALMSFACILITY NUMBER:
197607361
ADMINISTRATOR:NATALIE MALLONFACILITY TYPE:
740
ADDRESS:20548 GERMAIN STREETTELEPHONE:
(818) 772-7153
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
06/03/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John Mallon, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff dispensed medication that was not prescribed to resident.
Staff are confining resident to room.
INVESTIGATION FINDINGS:
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At 11:00am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted a subsequent visit to deliver final findings. LPAs met with the Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit.

During the initial visit, conducted on 12/08/25, LPA requested resident and staff roster. At 08:10am, requested copies of pertinent information which include, but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Staff Training, Medication Policy, Dementia Plan of Operation, Emergency Procedure Policy, Reporting Policy, relevant to the investigation. At approximately 08:15am, LPA conducted a physical plant tour. Between 08:20am - 9:30am, LPA conducted an interview with the Administrator, two (2) staff, four (4) residents and one witness.

On multiple occasions, LPA attempted to contact R1's Power of Attorney (POA) to discuss the above allegations. LPA left voicemails requesting a call back. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
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 5
Control Number 31-AS-20251203143852
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 PALMS
FACILITY NUMBER: 197607361
VISIT DATE: 06/03/2026
NARRATIVE
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Allegation: Staff dispensed medication that was not prescribed to resident.
It was alleged that the staff has been administering L-Tryptophan to R1 at night without physician’s order. To investigate this allegation, LPAs conducted an interview with the Administrator who confirmed that R1 is taking L-Tryptophan (2tab x bedtime). The Administrator stated that staff are required to dispense medications only according to the physician’s orders and to verify orders before administration. However, The Administrator acknowledged that no physician’s order was available for the medication that had been given to Resident (R1) nor was it recorded on Centrally Stored Medications and Destruction Record (CSMDR). The Administrator also confirmed that the centrally stored medication record had not been updated or completed properly for this medication. Staff interviewed also confirmed that medication was administered to R1, for almost six (6) months, without a valid and current physician’s order. Staff further confirmed that the medication was not documented in the CSMDR. However, it’s recorded on Medication Administration Record. Lastly, LPAs reviewed R1’s medication records, physician’s orders, and centrally stored medication logs. LPA did not observe a physician’s order for the medication in question. Additionally, LPA observed that the medication was not recorded in the Centrally Stored Medication and Destruction Record consistent with regulatory requirements. Photographs taken by LPA showing the missing entries in the centrally stored log and the absence of corresponding documentation in R1’s file. Therefore, based on interviews and LPAs record reviews this allegation is Substantiated.

Allegation: Staff are confining resident to room.
It was alleged that the staff installed a child safety cover on R1’s bathroom and bedroom doors to prevent R1 from eloping at night. To investigate this allegation, LPAs conducted an interview with the Administrator who denied instructing staff to confine any residents to their room. The Administrator also disclosed that R1 has diabetes and, for R1’s safety, staff placed a child-proof lock on R1’s bedroom door. When LPA requested R1’s care plan, physician’s orders, and any behavioral plan related to the use of the child-lock or to R1’s medical conditions, the Administrator was unable to provide any of these documents. LPA conducted review of facility records and did not observe an exception request being submitted to the Department. During the initial (12/08/25) visit and today’s visit (06/03/26) LPAs observed child-proof lock placed on R1’s bedroom door. Lastly, a credible witness, who visited this facility on 12/13/25, reported observing staff confining R1 to their room on several occasions. The witness stated they saw staff physically blocking the doorway and instructing R1 to remain inside. The witness provided consistent, detailed information supporting the allegation. Therefore, based on interviews and LPAs/credible witness’ observations this allegation is Substantiated.
Deficiency issued on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20251203143852
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 PALMS
FACILITY NUMBER: 197607361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2026
Section Cited
CCR
87465(a)(6)
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Incidental Medical and Dental Care: (a) ...Each facility must be in compliance with the following: (6) When requested by the prescribing physician... a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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Based on interview and record review, the licensee did not comply with the section cited above by failing to obtain Dr's order for R1's L-Tryptophan medication and properly documenting on CSMDR for accountability. This poses an immediate health and safety risk to residents in care.
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Type A
06/05/2026
Section Cited
CCR
87468.2(a)(6)
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Additional Personal Rights of Residents in Privately Operated Facilities:
(a) In addition to the rights... the following personal rights: (6) To make choices concerning their daily lives in the facility.
This requirement is not met as evidenced by:
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R1’s care plan will be updated to ensure behavior support strategies comply with Title 22. Administrator agreed to retrain all staff on resident personal rights and proper redirection techniques. Proof of training will be submitted to LPA by POC date.
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Based on interviews, LPAs/witness observation, licensee did not comply with the section cited above by allowing the staff to confined R1 in their room by placing a child-proof lock on a door knob. This poses an immediate 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/03/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20251203143852

FACILITY NAME:ROYAL PALMSFACILITY NUMBER:
197607361
ADMINISTRATOR:NATALIE MALLONFACILITY TYPE:
740
ADDRESS:20548 GERMAIN STREETTELEPHONE:
(818) 772-7153
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
06/03/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John Mallon, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not communicate with residents authorized representative about providing medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 11:00am, Licensing Program Analyst (LPA), Angela Panushkina and Huma Rahimi conducted a subsequent visit to deliver final findings. LPA met with the Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit.

During the initial visit, conducted on 12/08/25, LPA requested resident and staff roster. At 08:10am, requested copies of pertinent information which include, but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Staff Training, Medication Policy, Dementia Plan of Operation, Emergency Procedure Policy, Reporting Policy, relevant to the investigation. At approximately 08:15am, LPA conducted a physical plant tour. Between 08:20am - 9:30am, LPA conducted an interview with the Administrator, two (2) staff, four (4) residents and one witness.

On multiple occasions, LPA attempted to contact R1's Power of Attorney (POA) to discuss the above allegations. LPA left voicemails requesting a call back. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20251203143852
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 PALMS
FACILITY NUMBER: 197607361
VISIT DATE: 06/03/2026
NARRATIVE
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Allegation: Staff did not communicate with residents authorized representative about providing medications.

To investigate this allegation, LPA conducted an interview with the Administrator who denied the allegation and informed LPA that the R1’s Power of Attorney (POA) was notified about the bedtime medication administration, and R1’s POA expressed no concerns at that time. LPA attempted multiple times to contact the R1’s authorized representative/POA to obtain additional information and clarify the allegation. Attempts were made on the following dates/times:
· On 12/05/25 at 3:45pm – phone call, message left

· On 12/08/25 at 2:10pm – phone call, message left

· On 02/16/26 at 10:30am – phone call, message left

· On 04/17/26, at 3:45pm – phone call, message left

· On 05/04/26, at 9:00am – phone call, message left

· On 05/27/26, at 2:50pm – phone call, message left

Despite repeated attempts, the authorized representative could not be reached for confirmation or additional details. Based on interviews, record review, and unsuccessful attempts to gather additional information from the authorized representative/POA, there is insufficient evidence to determine that staff failed to communicate with the R1’s authorized representative/POA regarding medications. Therefore, this allegation is deemed Unsubstantiated, at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5