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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 07/02/2020
Date Signed: 07/02/2020 01:05:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR:LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:96CENSUS: 83DATE:
07/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lito Vitug - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Brian Balisi initiated a case management visit for the self-reported incident, which occurred on June 28, 2020. On 7/1/2020 Licensing received information that Resident 1 (R1) informed Administrator that Staff 1 (S1) allegedly inappropriately touched R1. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management was conducted telephonically at 10:30am with Lito Vitug, the facility administrator.

Between 10:30am - 11pm LPA conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the incident, to be emailed to the LPA by end of business day today.

LPA interview with Administrator revealed that he and his team are discussing whether to keep S1 on schedule or be allowed to continue to work on a modified basis. Admin stated that S1 has worked at the facility for over (3) years and has had no prior issues from either staff or residents. According to Admin R1 is in good health, and has not expressed any issued since the incident.

Going forward Female staff will conduct incontinent care for female residents and male staff will conduct the same for males. If ever a male staff has to conduct incontinent care for a female, another staff member will be required to be present. Same will be required for female staff and male resident.

Further review required prior to LPA concluding the investigation.A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature. 
SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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