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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 01/03/2024
Date Signed: 01/04/2024 08:55:53 AM


Document Has Been Signed on 01/04/2024 08:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 94DATE:
01/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lito VitugTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-deficiency visit. The LPA met with Lito Vitug, Executive Director (ED) and explained the reason for the visit. During the complaint investigation of complaint #29-AS-20230821084701, the following deficiencies were observed:

During an interview conducted on 08/24/2023 by the Department, the Administrator stated that R1 had recently begun smoking marijuana and drinking alcohol along with taking their regular medication. The Administrator stated they have noticed mild cognitive impairment in R1 since then. There was no Reappraisal done for R1’s change in condition. The Individual Service Plan (ISP) the facility submitted to the Department during the complaint investigation was dated 12/22/2022.

The Unusual Incident Report submitted by the facility, dated 08/15/2023, did not reflect that R1 had made an allegation against S1 for sexual abuse. The Executive Director, Facility Manager, and the Administrator were made aware of the allegations on 08/15/2023 and suspended S1 during the complaint investigation. The licensee did not submit a Report of Suspected Dependent Adult/Elder Abuse (SOC341) form.

Citations issued, exit interview was conducted and a copy of the report and Appeal Rights were issued..
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2024 08:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2024
Section Cited
CCR
87211(c)

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87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the licensing agency, and the local law enforcement agency within twenty-four (24) hours.
This requirement is not met as evidenced by:
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The licensee will schedule training on Mandated Reporting Requirements for all staff. Training must be conducted by an outside vendor. Submit training date to CCL by
Training must be conducted within the next 14 days. Submit confirmation of training, sign in sheet and training materials.
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Based on interviews, the licensee did not comply with the section cited above, as facility staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.

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Type B
01/19/2024
Section Cited
CCR87463(a)(3)

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87463(a)(3) Reappraisals(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a…
This requirement is not met as evidenced by:

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The licensee will submit a plan, detailing how the facility will maintain compliance of 87463(a)(3). Submit to CCL by due date
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Based on record review, R1’s Reappraisal was not updated when R1 began drinking alcohol, smoking marijuana and had a change of mental condition, which posed 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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