197608129-5-10-2021-29-AS-DPEA-C3DTWY-20210526150615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 05/10/2021
Date Signed: 05/10/2021 03:01:03 PM

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
03/05/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210305163828

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: 60	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Lito Vitug - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner

Staff locked resident in room

Staff took away residents telephone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegations. LPA met with Executive Director Lito Vitug and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour on 4/20/2021. On 4/20/2021, LPA conducted interviews with facility staff, residents and other relevant parties. Additionally, on 4/27/2021, LPA gathered and reviewed facility documentation pertinent to the allegation.

It was alleged that on March 3, 2021, Staff #1 (S1) entered the room of Resident #1 (R1), locked the room door, took away R1 personal phone and pushed R1 onto the bed while attempting to dress R1.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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-20210305163828

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: 05/10/2021

NARRATIVE

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Continued from 9099

Information gathered during the course of the investigation revealed, that the facility implemented a “buddy system” on 2/27/2021 to ensure two (2) staff are always present when providing services to R1 due to R1s behavior. Per records reviewed and interviews, S1 and S2 were providing assistance to R1 on date of the alleged incident. Interviews conducted did not reflect any signs of rough handling by S1. It was further revealed that no other residents witnessed or experienced any mistreatment from S1. Based on the information gathered, the department does not have sufficient evidence to determine that the staff locked resident in a room, took away the personal telephone and handled R1 in a rough manner. Therefore, the above allegations are deemed UNSUBSTANTIATED at this time.

Exit interview conducted/ A copy of report provided via e-mail for signature.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

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