197608129-9-28-2022-29-AS-JAPL-CKN2SH-20221028173910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 07/13/2022
Date Signed: 09/28/2022 01:23:53 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
11/17/2021 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20211117123100

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:	DATE:	07/13/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Lito Vitug		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not refill resident's medication.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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 4

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
11/17/2021 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20211117123100

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:	DATE:	07/13/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Lito Vitug		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not ensure that resident had a clean change of socks.
Resident has not been bathed in two months.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced complaint investigation at the facility. LPA met with Executive Director (ED) Lito Vitug and explained the reason for the visit.

LPA arrived at the facility at 10:25 a.m. and interviewed the ED at 10:48 a.m. LPA had interviewed Resident 1 (R1) and other staff during a prior visit. Staff confirmed it had been at least a week since R1 had been bathed or had socks changed because R1's preferred caregiver was on vacation and R1 would aggressively refuse care from other caregivers. R1 indicated they preferred a particular caregiver over the others as that caregiver knew how to handle them in a way that did not cause R1's nerve pain to flair up. However, R1 indicated they did not know that caregiver was on vacation and had they known that they would have settled on a different caregiver to provide bathing/cleaning and clothing changes.

continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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 4

Control Number 29-AS-20211117123100

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: 07/13/2022

NARRATIVE

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While there is not enough evidence to indicate R1 went an entire two months without being bathed, based on interviews with staff and R1, R1 went at least a week without being bathed or having socks changed. According to the ED, staff and R1, residents are supposed to be bathed twice a week. R1 required assistance with bathing and daily clothing changes. There is no indication the facility reached out to R1's physician or other health services when R1 continued to refuse care.

Therefore, the allegations the faciltiy failed to bathe R1 or change R1's socks is deemed Substantiated at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the deficiencies listed on 9099-D were confirmed and cited.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20211117123100

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: 07/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/20/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	The ED will train staff regarding bathing and clothing changes. If a resident refuses, staff must notify management so they can make other attempts and/or notify responsible parties and physicians. A copy of the training will be provided to CCL by 07/20/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews with staff and R1, R1 was not bathed for at least a week and did not have a change of socks in at least a week, which poses a potential health and safety risk to 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4