197608129-1-30-2023-29-AS-CYEE-CNKLV7-20230130080502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 01/27/2023
Date Signed: 01/30/2023 08:05:11 AM

Document Has Been Signed on 01/30/2023 08:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 81	DATE:	01/27/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Joey Vitug, Manager		TIME COMPLETED:	09:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Christine Yee, conducted an unannounced Case Management visit to deliver findings of the investigation conducted as a result of an incident that was reported to the Department on October 13, 2022. It was alleged that a resident (R1) was sexually abused by facility staff (S1). LPA Yee met with Joey Vitug, Manager, and explained the reason for the visit. Lito Vitug, Executive Director arrived a little later to participate in the visit. Below are the results of the investigation: On 10/13/2022, the Community Care Licensing Division (CCLD) received a self-reported Unusual Incident/Injury Report (LIC 624) and a Report of Suspected Elder Abuse (SOC341) reporting that Resident #1 (R1) was sexually fondled by facility Staff #1 (S1). R1 reported to their visiting Home Health (HH) Physical Therapist (PT) that S1 touched their breast multiple times, repeatedly throughout the years. The PT reported the incident to the Executive Director (ED) who also spoke with R1 and S1 regarding the incident. S1 refuted the claim and denied the allegation. R1 added that S1 would sometimes pucker up their lips in a kissing motion when looking at R1. When the ED asked R1 to provide details and a timeline of the incident, the information was scattered and conflicting, continuously insisting that they were not a victim. R1 denied fear or feeling threatened by S1 and insisted that S1 was harmless and felt safe at the facility. The ED suspended S1 for internal continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE	FACILITY NUMBER: 197608129
	VISIT DATE: 01/27/2023

NARRATIVE

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investigation and was prohibited to enter R1’s room to assist if the investigation warranted S1’s return to work. The complaint was referred to Community Care
Licensing Investigations Branch (IB) and assigned to Investigator Laarni Santiago.

Investigator Santiago conducted interviews on 10/27/2022, from approximately 12:19pm to 1:25pm, with residents and the Executive Director; on 11/14/2022, at approximately 10:31am, with R1; on 11/18/2022, at approximately 10:36am, with the Home Health Physical Therapist; and on 01/06/2023, from approximately 9:36am to 11:03am, with S1, staff, and residents. In addition, the investigator reviewed facility file documents related to R1 and the investigation.

On 01/06/2023, at approximately 11:10am, the investigator spoke with the Los Angeles Police Department (LAPD). The Deputy in charge reported that he attempted to get in contact with R1, but R1 refused to speak with him. The Deputy tried to dialogue over the door, but R1 refused to come out of the room. The Deputy advised that they would be closing out the case since R1 refused to be interviewed.

R1 was admitted to the facility on 05/22/2015. R1’s physician report, dated 06/23/2022, revealed that R1 was diagnosed with a Seizure Disorder, Hypothyroidism and Hyperlipidemia. R1 was able to follow instructions and communicate their needs. R1’s capacity for self-care suggests that they required assistance with bathing, dress/grooming and toileting, with an exception of feeding. The report documents that R1 was able to leave the facility unassisted, able to administer and store their own medications and R1’s ambulatory status was listed as non-ambulatory.

continued on LIC809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE	FACILITY NUMBER: 197608129
	VISIT DATE: 01/27/2023

NARRATIVE

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During the interview process, R1 stated that S1 fondled their breast over their clothes but did not determine that it was for sexual gratification. S1 refuted the claim and denied that they fondled R1’s breast or touched R1 inappropriately on any part of
R1’s body. The resident and staff interviews verified that S1 does not help with any of their care and reported that S1 only handled maintenance and driving residents
to their appointments. The PT reported the allegation but did not witness the incident. There were no witnesses to corroborate the incident and resident and staff interviews suggest that S1 had no history of sexual assault or abuse. Based on R1’s statements and lack of evidence to support the allegation, sexual assault could not be established or confirmed. Therefore, the allegation of “Sexual Abuse: Resident #1 (R1) was sexually abused by facility Staff #1 (S1)” is deemed Unsubstantiated at this time.

Exit interview was conducted with Lito Vitug and a copy of the report given.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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