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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 05/03/2023
Date Signed: 05/03/2023 03:54:44 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
04/27/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230427141353
FACILITY NAME:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR:LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:96CENSUS: 89DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lito VitugTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff are not properly addressing insect infestation in facility.
Facility staff are not assisting resident with scheduled showers.
Facility staff are not assisting resident with their toileting needs in a timely fashion.
Staff did not report an incident involving resident as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations listed above. The LPA was greeted by staff, and staff contacted the Executive Director via phone to inform them of the visit. The LPA met with Executive Director, Lito Vitug at 11:58 a.m., and explained the reason for the visit.

LPA Urena conducted residents’ interviews from 10:35 a.m. to 11: 50 a.m., conducted staff interviews at 11:15 a.m., and 11:55 a.m. The LPA interviewed the ED from 11: 58 a.m. to12: 56 p.m. Conducted records review from 1:30 p.m. to 2:00 p.m.

Continues on LIC 9099 C...(page 2.)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20230427141353
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: 05/03/2023
NARRATIVE
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Page 2.
Facility staff are not properly addressing insect infestation in facility.

On the allegation that ‘Facility staff are not properly addressing insect infestation in facility’; it is the concern of the complainant that the facility has bedbugs, and that there has been a repeated problem with bed bugs at the facility. To investigate the allegation, the LPA conducted residents’ interviews, inspected rooms, and requested records of the facility’s ongoing fumigation services, and maintenance records. The inspection of the rooms, and beds revealed that nine out of nine rooms were free of bug infestations; and three out of nine mattresses were covered with a mattress liner. Residents’ interviews revealed that eight out of nine residents stated that they have not had a bedbug infestation. R1 stated that they had bedbugs around mid-April 2023, got bitten around the ankles, and other parts of their body; furthermore, R1 stated that staff came around to spray the room, and to wash the linens. R1 declined to be relocated to another room for the heat treatment to take place. R1 stated, “I haven’t seen any bugs lately”.
Additional residents’ interviews revealed that staff have come around to the rooms fumigating for bugs. The interview with the ED revealed that bug infestations are dealt with two methods: If the facility experiences an active bug infestation, maintenance uses a ‘heat treatment’ in which the resident has to be relocated, and a heat machine is placed in the room to heat up the room up to 190 degrees Fahrenheit for 24 hours. After the 24 hour heat treatment, the room is allowed to cool down for half a day, before returning the resident to their room. The second method for bug problems is a follow up, and preventive measure, in which rooms are fumigated at intervals of a week and a half to ensure bug eggs are killed, to prevent infestation. Maintenance records revealed that an independent fumigation company is contracted to conduct monthly fumigation for pest, and rodent control. Records indicated that fumigation was done in January, February, March and April of 2023.

Based on the information obtained through interviews, there is evidence to support that bedbugs were seen in one room of the facility only. The facility staff appropriately addressed the insect problem, and took action to treat the room and fumigate the room in a timely manner. Therefore, the allegation that the Facility staff are not properly addressing the insect infestation is deemed Unsubstantiated at this time.

Continues Page 3...
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230427141353
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: 05/03/2023
NARRATIVE
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Page 3.
Facility staff are not assisting resident with scheduled showers.
On the allegation that the ‘Facility staff are not assisting resident with scheduled showers’; it is the concern of the complainant that when they visited the resident #1 (R1) during the week, the resident had not taken a shower since the previous week’s weekend. To investigate the allegation, the LPA conducted residents’ interviews, staff interviews, and reviewed the residents’ shower schedule. Records review revealed that residents receive assistance with showers two times a week or more often if necessary. R1 stated that they receive assistance with showers twice a week, on Wednesdays and Saturdays, and that their last shower was last Saturday(04/29/2023). Residents’ interviews revealed that they receive assistance with showers twice a week. Staff interviews revealed that they provide residents who need assistance to shower based on the shower schedule, and sometimes some residents require showers more than twice a week due to their needs. Shower schedule indicates the residents that need assistance with showers twice a week.

Based on the information obtained through interviews, and record review, there is not enough evidence to support the allegation that Facility staff are not assisting resident with scheduled showers. Therefore, the allegation is deemed Unsubstantiated at this time.

Facility staff are not assisting resident with their toileting needs in a timely fashion.
On the allegation that ‘Facility staff are not assisting resident with their toileting needs in a timely fashion’; it is the complainant’s concern that due to the lack of care from the facility staff, the resident does not get the help they need in timely manner, when they need help going to the rest room. To investigate the allegation, the LPA conducted residents’ interviews, staff interviews, and reviewed the residents’ incontinent schedule. Residents’ interviews revealed that five out of five residents stated that they do receive assistance with their toileting needs. Sometimes it may take staff more time than usual, but they usually respond within 20 minutes. The LPA interviewed R1 about their toileting needs, and R1 stated, ‘I can get up on my own and go to the bathroom by myself; I don’t need assistance’. Staff interviews revealed that they check on residents about every two hours, and whenever the resident may request assistance.

Based on the information obtained through interviews, and record review, there is not enough evidence to support the allegation that Facility staff are not assisting resident with their toileting needs in a timely fashion. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230427141353
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: 05/03/2023
NARRATIVE
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Page 4.

Staff did not report an incident involving resident as required.
On the allegation that ‘Staff did not report an incident involving resident as required’; it is the complainant’s concern that the resident had a fall two weeks ago (mid-April 2023) when R1 was walking in their bedroom. R1 fell, and was unable to get up on their own. R1 had to wait on the floor, until a staff showed up in their bedroom to help them up. The complainant stated that the facility did not report this fall to the responsible party, and is unsure if the facility shared this incident with doctor. To investigate the allegation, the LPA interviewed R1, and R1 stated that they have not fallen this year(2023), they recall falling twice last year, once during the middle of the night and another time during the day. The LPA interviewed the responsible parties (RPs) about these two falls last year, and they stated that they were aware of the falls. Additionally, R1 was recently admitted to the hospital, and both RPs were informed by the facility staff when R1 was taken by ambulance to the hospital.

Based on the information obtained through interviews; there is not enough evidence to support the allegation that Staff did not report an incident involving resident as required. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interviewed was conducted with the ED, Lito Vitug. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4