197608129-4-5-2023-29-AS-JAPL-CQYUYM-20230417160011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:33:55 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
03/03/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230303094141

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:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lito Vitug		TIME COMPLETED:	03:33 PM

ALLEGATION(S):

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Facility staff are not caring for and responding to resident in a timely manner.

INVESTIGATION FINDINGS:

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On 04/05/2023, Licensing Program Analyst(LPA), Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegation above. The LPA arrived at the facility, and spoke with the Executive Director (ED) Lito Vitug, and explained the reason for the visit.

On 03/07/2023, Licensing Program Analyst(LPA), Sandra Urena conducted an unannounced visit to investigate the allegation above. The LPA arrived at the facility at 2:10 p.m., met with the Executive Director (ED), and explained the reason for the visit. LPA Urena interviewed residents, and the ED from 2:15 p.m. to 4:30 p.m. and conducted records review.

Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20230303094141

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: 04/05/2023

NARRATIVE

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On the allegation that ‘Facility staff are not caring for and responding to resident in a timely manner; the complainant’s concern is that care staff is not caring, and responding in a timely manner to R1, due to R1 not able to make monthly payments . The LPA interviewed the complainant on 03/07/2023 at approximately 3:30 p.m., and the interview revealed that they received a concern from R1, who stated that the care staff were taking too long to respond to the signal system(pull cord), and they thought it was because their SSI payment has not been received by the facility. To investigate the allegation, LPA Urena interviewed five residents about the timeliness of the care staff responding to the signal system. Five out of five residents stated that the time varies, but it can take anywhere from 15 minutes to two hours. The LPA interviewed R1, and R1 stated that the care staff sometimes takes long, more than 20 minutes to respond. The R1 stated that the are pretty much independent, but needs someone to watch them when they need to go to the restroom, because they are prone to falling. The LPA interviewed the ED about the signal system, and the respond time for caregivers to provide assistance. The ED stated that it varies depending on the time of the day, however the ED said that the care staff usually takes no more than fifteen(15) minutes to respond.

Based on the information obtained through the interviews, there is not enough evidence to support the allegation that facility staff are not caring for and responding to resident in a timely manner due to facility not receiving the SSI payment for R1. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted with the Executive Director, and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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