197608129-2-22-2023-29-AS-DPEA-CPG38T-20230227170205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 02/22/2023
Date Signed: 02/22/2023 03:47:02 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
04/13/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210413120631

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: 83	DATE:	02/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lito Vitug - Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident with dementia eloped due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the allegation listed above. Upon arrival LPA met with Executive Director Lito Vitug and explained the reason for the visit.

On 04/13/2021, the Department received a complaint regarding allegations that Resident with dementia eloped due to lack of supervision.
On 04/16/2021, from 2:30pm - 3:30pm, LPA conducted an unannounced initial complaint visit virtually due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). LPA virtually conducted a physical plant tour, interviewed Executive Director and reviewed and obtained copies of pertinent documentation relevant to the investigation.
Today, LPA conducted a subsequent visit and conducted a physical plant tour, interviewed (9) staff, (9) residents and reviewed and obtained additional pertinent documents relevant to the investigation.

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: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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-20210413120631

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: 02/22/2023

NARRATIVE

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Continued from 9099

It was reported that Resident with dementia eloped due to lack of supervision as it was alleged that Resident 1 (R1), visited a local hospital and appeared to be confused and was not able to communicate their primary residence. LPA records review of R1's physicians report revealed that R1 does not have a diagnosis of dementia and that R1 is able to leave the facility unassisted. LPA records review of daily schedule revealed there is sufficient staffing scheduled throughout the day. LPA interview with (9) staff revealed R1 occasionally leaves the facility and always notifies staff of where R1 is going and R1 also notifies them upon return. Interviews with staff further revealed there are at least (3) caregivers in the morning, (3) in the afternoon and (2) during NOC. Also scheduled throughout the day are cleaning staff, med techs, and office staff. LPA interview with R1's POA, who stated they speak to R1 frequently, revealed, R1 is capable of leaving the facility unassisted and returning to the facility. POA did not express any potential or immediate concerns of lack of supervision at the facility and also noted that R1 is aware to either sign out or notify a staff member when exiting the facility. LPAs interview with (9) residents revealed there is a sufficient amount of staff scheduled throughout the day and into the evening. All residents interviewed did not express any immediate or potential concerns for lack of supervision. Based on information gathered during this and previous visits, the department does not have sufficient evidence to prove this allegation occurred. Therefore the allegation that resident eloped due to lack of supervision has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC9099 (FAS) - (06/04)

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