197608129-3-9-2023-29-AS-JAPL-CQ8TD6-20230324143749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 03/08/2023
Date Signed: 03/09/2023 08:53:29 AM

Substantiated

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
01/19/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220119154144

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: 85	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Lito Vitug		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident left soiled for an extended period of time
Resident unlawfully evicted while in care

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 11:35 a.m. and met with the ED at 11:40 a.m. regarding this complaint which the Department received on 1/19/2022. LPA Salia Walker had conducted interviews with the ED on 1/25/22 at 1:28 p.m. and 2/1/22 at 2:49 p.m. LPA Walker interviewed residents on 2/1/22 at 3:17 p.m. LPA Walker obtained documents on 1/25/22 at 2:15 p.m. and 2/1/22 at 2:49 p.m.

Regarding the allegation Resident left soiled for an extended period of time: This allegation regarding the same incident for the same time period was previously investigated under complaint control number 29-AS-20211117123100 and the allegtion was substantiated by LPA Camara.

(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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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-20220119154144

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: 03/08/2023

NARRATIVE

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LPA Camara had interviewed Resident 1 (R1) and staff regarding the allegation. Staff confirmed it had been at least a week that R1 had not been bathed. R1 refused to wear diapers and was in soiled sheets. R1 suffers from nerve pain and had only one caregiver they would allow to bathe them or assist with incontinence care or grooming. During the time, which was early to mid November 2021, R1's preferred caregiver was on vacation and R1 would aggressively refuse care from other caregivers. R1 explained to LPA that 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 stated they did not know their preferred caregiver was on vacation and had they known they would have settled on a different caregiver to provide bathing, cleaning and clothing changes. According to interviews with staff, residents are supposed to be bathed twice per week. R1 required assistance with bathing and changing. Therefore, based on these interviews the allegation is substantiated at this time. As previously noted, this same allegation for the same time period was already cited on a prior complaint.

Regarding the allegation Resident unlawfully evicted while in care: LPA Walker conducted a file review and found a copy of an eviction letter which stated it was served on R1 on 1/7/2022 by facility administrator Lori McKay. The eviction notice did not contain all of the required information, therefore the eviction was unlawful. LPA Walker interviewed the ED who said they did not intend to kick R1 out of the facility but the eviction was served on R1 due to R1's refusal of care and refusal to follow the facility's house rules. R1 was known to be extremely disrespectful to staff by being verbally abusive and using profane language toward staff who were there to help R1. The ED stated R1 wanted to leave the facility and was working with outside agencies to find a facility which could offer a higher level of care to R1. R1 eventually moved out but was never evicted from the facility. While R1 was never technically evicted from the facility the eviction notice dated 1/7/2022 was served on R1 and lacked the required information, therefore the allegation 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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220119154144

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: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2023 Section Cited CCR 87224(d)(1)(B)	1 2 3 4 5 6 7	87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information:	1 2 3 4 5 6 7	Licensee will review 87224 Eviction Procedures and submit a written statement of understanding the requirements to CCL on or before 3/15/2023.
	8 9 10 11 12 13 14	(B) Resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following: 1. Referral services that will aid in finding alternative housing. 2. Case management organizations which help manage individual care and service needs.	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on documents obtained and interviews with staff and R1, R1 was served an unlawful eviction notice on 1/7/2022, which poses a potential health and safety risk to residents in care.
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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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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