197608129-6-2-2021-29-AS-KHEN-CHSNX8-20220830105044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 06/02/2021
Date Signed: 06/02/2021 04:30:53 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
04/02/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210402154201

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: 63	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lito Vitug - Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not assist resident with medications as needed.
Staff screamed at resident.
Staff did not provide laundry service in a timely manner.
Staff did not respond to call button in a timely manner.
Resident was not accorded dignity in relationships with staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegations. LPA met with Executive Director Lito Vitug and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour virtually on 04/05/2021 as well as interviewed Administrator. On 4/19/21 LPA conducted interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

Regarding allegation that staff did not assist resident with medications as needed, it was reported that staff are not letting medication fully dissolve into applesauce before being administered to Resident 1 (R1). LPA reviewed and obtained copies of R1’s medication records, physician’s report, and doctor’s orders. Review of these documents confirms that staff are to crush medications and administer with applesauce. LPA’s interview with staff revealed that Staff 1(S1) and Staff (S2) typically are the ones who administer the medications for R1, and all believed that S1 and S2 properly followed doctor’s orders to crush medications for R1.

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: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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 29-AS-20210402154201

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: 06/02/2021

NARRATIVE

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Continued from 9099

LPA’s interview with (10) residents revealed that most have not had any issues in receiving assistance with their medications. Most of the residents did not express any immediate or major concerns regarding staff not assisting them with medication as well. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff did not assist resident with medications as needed. Therefore, this allegation has been UNSUBSTANTIATED at this time.

Regarding allegation that staff screamed at resident, interviews conducted with (10) residents revealed that most have not ever witnessed or experienced any staff screaming at them or R1. Most residents felt that there were no immediate or major concerns regarding staff screaming at any resident. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff screamed at resident. Therefore, this allegation has been UNSUBSTANTIATED at this time.

Regarding allegation that staff did not provide laundry service in a timely manner, LPA interview with staff revealed that laundry service for R1 is done every other day at the request of R1. Most residents get laundry service completed once or twice a week. LPA’s interview with (10) residents further revealed that most did not have any concerns with the laundry service. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff did not provide laundry service in a timely manner. Therefore, this allegation has been UNSUBSTANTIATED at this time.

Regarding allegation that staff did not respond to call button in a timely manner, LPA’s interview with (10) 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. On 4/19/2021, LPA observed R1 press the call button in their room and staff arrived within 2 minutes. Based on the information gathered during this and previous visits, the department does not have sufficient evidence that staff did not respond to call button in a timely manner. Therefore, this allegation has been UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210402154201

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: 06/02/2021

NARRATIVE

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Regarding allegation that resident was not accorded dignity in relationships with staff. During the investigation, LPA did not observe any negative interactions or treatments towards residents during any initial or subsequent visits. Interviews conducted with (10) residents revealed that most had not observed any harsh treatments, disrespect or negative interactions from staff with themselves or R1. LPA interview with staff revealed that most of them maintained appropriate working relationships with residents. Based on the information gathered during this and previous visits, the department does not have sufficient evidence that resident was not accorded dignity in relationships with staff. Therefore this allegation has been UNSUBSTANTIATED at this time.

Exit interview conducted / report issued and sent via E-Mail.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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