197608129-4-5-2023-29-AS-JAPL-CQYUHS-20230417153626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:35:30 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
02/24/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230224111439

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:	LitoVitug		TIME COMPLETED:	03:33 PM

ALLEGATION(S):

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Staff abandoned resident at hospital.

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 listed above. The LPA arrived at the facility, and met with the Executive Director (ED) Lito Vitug. The LPA explained the reason for the visit.

On 03/02/20203, LPA Urena interviewed the ED from 5:10 p.m. to 5:45 p.m. The LPA requested records for review at 5:47 p.m. The LPA interviewed the complainant on 02/27/2023 from 12:05 p.m. to 12:22 p.m., and again on 03/27/2023 at 11:05 a.m. The LPA interview (R1) on 03/02/2023 from 10:45 a.m. to 11:30 a.m.
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-20230224111439

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 ‘Staff abandoned resident at hospital’; the complainant’s concern is that the facility staff refused to accept back the resident at the facility, and abandoned R1 at the skilled nurse facility(SNF). To investigate the allegation, the LPA interviewed the complainant, and the interview revealed that the SNF contacted the facility administrator to inform them that R1 was being discharged from the SNF, because R1 wanted to go back to the facility. However, the complainant added that R1’s mobility had not improved, and required four people assistance to be transferred from place to place. On 03/27/2023, the LPA contacted the complainant, and conducted a second interview about R1. The complainant stated that due to the lack of R1’s participation in their physical therapy, R1 will need a higher level of care than what the facility can provide, consequently the R1 will remain at the SNF until the R1’s mobility increases, and can independently transfer from place to place. On 03/02/2023, the LPA conducted a collateral visit to interview R1. The interview revealed that R1 wants to return to the facility, and was told personally by the facility administrator that they have R1’s room ready, and can return, as soon as their physical therapy indicates that they are ready for discharge. The LPA interviewed the ED , and the interview revealed that the ED visited R1 at the SNF, and explained to R1 that their room at the facility was waiting for them as soon as the PT was completed and that R1 was ready to return with mobility that would enable them to transfer from place to place.

Based on the observation, and information obtained, there is not sufficient evidence to support the allegation that staff abandoned the resident at hospital. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview was conducted. 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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