197608129-9-8-2021-29-AS-DPEA-CH8MD9-20220812093042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 08/27/2021
Date Signed: 09/08/2021 03:02:39 PM

Unsubstantiated

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
06/11/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200611120014

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: 71	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lori McKay		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff not responding to residents calls in a timely manner
Staff speaks rudely to residents
Staff not providing adequate food service
Staff not properly cleaning residents rooms
Staff not providing residents with a comfortable environment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. Upon arrival LPA met with Lori McKay Administrator and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour virtually on 6/16/2020. On 5/24/2021, LPA conducted interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegations.

It was alleged that Staff are not responding to residents calls in a timely manner. LPA’s interview with (13) residents revealed that most did not have any immediate or major concerns when they request service from staff. Most residents stated that staff typically arrive within 5 minutes. During the evening shifts, most residents stated they do not recall waiting much longer than 5 - 10 minutes as well. During the investigation
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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 5

Control Number 29-AS-20200611120014

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: 08/27/2021

NARRATIVE

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(continued from 9099)

LPA observed residents press the call button in their room and staff would typically arrive in a timely manner. Based on the information gathered during this and previous visits, the department does not have sufficient evidence that Staff are not responding . Therefore, this allegation has been UNSUBSTANTIATED at this time.

It was alleged that staff speaks rudely to residents, LPA interview with (13) residents revealed that all residents have not witnessed Staff 1 interact with any resident negatively. Most residents did not express any immediate concerns of their interactions with S1. LPA interviews with staff revealed no staff has witnessed S1 speak to any resident or staff rudely or in a negative tone. During the investigation LPA observed S1 answer multiple phone calls throughout the day and did not observe S1 speak with anyone with a negative tone or in a rude manner. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff speaks rudely to residents. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that staff are not providing adequate food service. LPA interview with (13) residents revealed that most residents did not express any immediate or major concerns regarding food service. LPA reviewed and obtained a copy of the facility menu and observed a variety of food being served. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff are not providing adequate food service. Therefore, the above allegation is UNSUBSTANTIATED at this time.

It was alleged that staff are not properly cleaning residents rooms, LPA interview with (13) residents revealed that most residents did not express any concerns regarding staff not properly cleaning rooms. During the course of the investigation LPA observed staff cleaning common areas and bedrooms on multiple occasions. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff are not properly cleaning residents rooms. Therefore, the above allegation is UNSUBSTANTIATED at this time.

(Continued on 9099-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20200611120014

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: 08/27/2021

NARRATIVE

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(Continued from 9099-C)

It was alleged that staff are not providing residents with a comfortable environment. LPA interview with (13) residents revealed that most residents did not express any immediate or major concerns about their living environment. All residents did not report any other resident playing loud music throughout the day, however LPA did observe music being played over speakers in the hallways and the common areas. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff are not providing residents with a comfortable environment. Therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report issued, signed and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

Page: 5 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200611120014

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: 71	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lori McKay - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents carpet is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. Upon arrival LPA met with Lori McKay Administrator and explained the reason for the visit. During the course of the investigation, LPA conducted a physical plant tour virtually on 6/16/2020. On 5/24/2021, LPA conducted interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.
It was alleged that residents carpet is in disrepair. During the investigation LPA did observe multiple stains in Resident 1's (R1)s carpet and areas of the carpet that appeared to be severely distressed and coming off of the floor. LPA did not observe any other carpets in disrepair in the rooms of other residents interviewed. Based on the information gathered during this and previous visits, the department does have sufficient evidence to determine that residents carpet is in disrepair.
Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the deficiencies listed on 9099-D were confirmed and cited.
Exit interview was conducted. Report issued, Appeal rights discussed. All documents sent via email.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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 5

Control Number 29-AS-20200611120014

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/17/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) 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:	1 2 3 4 5 6 7	LIcensee agreed to either have carpet cleaned or replaced by the POC date. Licensee will send pictures of cleaned or newly installed floor to LPA via email by POC date.
	8 9 10 11 12 13 14	Licensee failed to keep the carpet in the unit of R1 clean and well kept. During the investigation LPA observed the carpet to have multiple stains in various areas. This poses as a potential health and safety riske to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5