197608129-4-7-2021-31-AS-KBUY-BZWPJ8-20210409112106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 04/07/2021
Date Signed: 04/07/2021 02:09:44 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 31-AS-20200403143708

FACILITY NAME:	RESIDENCES AT ROYAL BELLINGHAM, THE		FACILITY NUMBER:	197608129
ADMINISTRATOR:	LORI MCKAY		FACILITY TYPE:	740
ADDRESS:	12229 CHANDLER BOULEVARD		TELEPHONE:	(818) 980-2997
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	96	CENSUS: 65	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Lito Vitug, Owner/Executive Director		TIME COMPLETED:	01:57 PM

ALLEGATION(S):

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Facility not centrally storing residents’ medications.

INVESTIGATION FINDINGS:

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At 1:50 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted a meeting to review the final findings on the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via FaceTime with Lito Vitug, facility owner and Executive Director. LPA explained the purpose of today’s visit which was to inform on the outcome of the investigation.

On the allegation “Facility not centrally storing residents’ medications,” the complainant’s concern was that the Resident’s #1 (R1) rights were violated because staff attempted to take control of R1’s medications. To investigate this allegation, LPA interviewed the complainant and facility administrator; and reviewed facility records.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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 31-AS-20200403143708

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE	FACILITY NUMBER: 197608129
	VISIT DATE: 04/07/2021

NARRATIVE

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The complainant states that R1 was being told R1 would have to look for another facility to live unless R1 relinquished control of R1’s medications to facility staff. On 4/6/2020 and 3/28/2021, the administrator reports that the facility was concerned with R1’s health as they believed R1 was taking too much medicine and observed R1 falling several times. On 2/08/2020, the administrator contacted R1’s physician, Person of Responsibility (POR), and Assisted Living Waiver program to inform of the resident’s falls and request the facility take over R1’s medication. R1’s physician, POR, and ALW representative determined it was in the resident’s best interest to continue managing R1’s own medications, therefore, the administrator complied.

Based on this investigation, LPA found sufficient evidence to support that the facility made every effort to ensure the safety and well-being of the resident. As a result, regarding the allegation that, “Facility not centrally storing residents’ medications”, the finding is Unsubstantiated.

At 1:57 pm, a video chat exit interview was conducted with Lito Vitug and an electronic copy of the report was emailed for signature and to be returned via email to LPA.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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