197608129-3-3-2023-29-AS-DPEA-CQ4UFB-20230320153229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 03/03/2023
Date Signed: 03/03/2023 09:18:46 AM

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
04/28/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210428161634

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: 84	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Joey Vitug Assistant Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident in care has scabies

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to the deliver findings for the allegation listed above. Upon arrival LPA met with Assistant Administrator Joey Vitug and explained the reason for the visit.

During the investigation, LPA conducted a physical plant tour on 05/03/2021, as well as interviewed Executive Director and Administrator. On 02/22/2023, LPA conducted interviews with nine (9) residents and nine (9) staff during a subsequent visit investigating allegations on a separate complaint.
It was reported that resident in care has scabies, as it was alleged that Resident 1 (R1), contracted scabies while in care. LPA’s interview with Lito along with records review of R1’s file revealed that R1 was first admitted into the facility on 01/19/2021. Based on interviews and records reviewed, R1 was transported and admitted to the local hospital on 01/28/2021. Thereafter, R1 was transported to a Skilled Nursing Facility (SNF) for further care and resided at the SNF from 03/09/2021 to 04/20/2021. R1 was discharged from the SNF and returned to the facility on 04/20/2021.

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: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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-20210428161634

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: 03/03/2023

NARRATIVE

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Continued from 9099
The Discharge summary from SNF, dated 04/20/2021, notated an observation of red and dry skin on the Mid-back of R1 however, there was no indication of scabies. Facility did not conduct a pre-appraisal on R1 prior to accepting R1 back to the facility though, on 04/22/2021, Staff 1 (S1), informed Administrator Lori McKay of redness on R1’s back. McKay informed R1’s primary care physician and awaited instructions. On 04/23/2021, R1 went to R1s dialysis appointment, at which time R1 was transported back to a local hospital due to low blood pressure. R1 did not return to the facility.

LPA interview with the family member of R1 revealed that R1 never complained of any symptoms related to scabies while residing at the facility. Based on R1’s Physician Report dated 04/19/2021, R1 is able to communicate R1s needs and able to follow instructions. Further interview with R1s family member revealed that R1 was in communication with the family member and that R1 was mostly impacted with symptoms of scabies while residing at the SNF. Per the Reporting Party (RP) it was unclear where R1 was infected with scabies, however, upon admission to the hospital on 04/23/2021, R1 was present with scale and excoriations all over R1s trunk and extremities with pruritus.

Based on information gathered during this and previous visits, even though R1 was admitted back to the hospital with scabies on 04/23/2021, the department does not have sufficient evidence to determine that R1 contracted scabies while in care of the facility. Therefore, the allegation that resident in care has scabies has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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