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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 07/13/2022
Date Signed: 09/28/2022 01:24:21 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
11/16/2021 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20211116135526
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: DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Lido VitugTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not observe issues with resident's catheter placement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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) during a prior visit. R1 indicated they managed their own catheter. The catheter was a condom catheter but due to anatomical changes it was no longer usable so R1 switched to a bed urinal. R1 indicated the staff assist with cleaning out the urinal but otherwise R1 is capable of using the urinal without assistance. Based on R1's statement that the facility staff did not need to assist with the catheter and R1 self-managed the condom catheter, the allegation staff did not observe issues with R1's catheter placement is deemed Unsubstantiated at this time. Exit interview conducted and report issued via email.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 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 2
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
11/16/2021 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20211116135526

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: DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Lido VitugTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that the resident was kept clean and dry.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 R1 refused incontinence care and bathing as R1's preferred caregiver was on vacation. 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 incontinence care and bathing. Therefore, the allegation staff did not ensure R1 was kept clean and dry is Substantiated at this time. This deficiency was already cited today for R1 under complaint number 29-AS-20211117123100.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 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 2