197608129-1-4-2024-29-AS-KLOZ-CZY3QY-20240129172754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 01/03/2024
Date Signed: 01/04/2024 08:52:40 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/21/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230821084701

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: 91	DATE:	01/03/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Lito Vitug		TIME COMPLETED:	04:37 PM

ALLEGATION(S):

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Staff molested resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with the Executive Director Lito Vitug and explained the reason for the visit.

On 08/21/2023, the Department received a complaint reporting the alleged sexual abuse of a facility resident #1 (R1) by a staff #1 (S1). R1 reported that S1 touches R1 in their private areas and has made R1 touch S1’s private areas. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20230821084701

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/03/2024

NARRATIVE

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On 08/22/2023, from 3:05pm to 4:45pm, Licensing Program Analyst (LPA) Sandra Urena conducted an initial visit to investigate the allegation listed above. LPA Urena met with Executive Director Lito Vitug and Administrator Lori McKay and explained the reason for the visit. At 3:15pm, the LPA requested records pertinent to the investigation and interviewed the Administrator and Executive Director between 3:15pm and 4:30pm. The LPA determined further investigation was required prior to issuing findings.

Investigator Douglas conducted interviews on 08/24/2023, at approximately 2:45pm, with R1 and the Administrator; on 10/02/2023, at approximately 1:00pm, with S1; and on 11/15/2023, at approximately 1:40pm, with Staff #2 (S2). In addition, the investigator reviewed the facility file documents related to R1. The investigator also contacted the Los Angeles Police Department North Hollywood station and was informed that detectives determined no crime was committed in reference to the allegation.

According to R1’s Physician’s Report, dated 03/17/2023, the primary diagnosis was indicated as Hypertension, Congestive Heart Failure, and Bipolar. The secondary diagnosis was indicated as Arthritis. The report documented Mild Cognitive Impairment. In the Mental Condition section of the report, under Confused/Disorient, neither yes nor no was indicated by R1’s doctor. Whether R1 was able to bathe and/or dress /groom self was also not indicated by R1’s doctor. The doctor did indicate that R1 was not able to care for their own toilet needs.

The Individual Service Plan (ISP) dated 12/22/2022, indicated R1’s needs and concerns included risk for impaired social interaction and anxiety related to Parkinson’s disease, risk for impaired social interaction related to depression, risk for self-directed violence related to depression and history of 5150 secondary to psychosis, and risk for disturbed thought process related to nonreality based thinking and impaired judgement.

Per the Unusual Incident Report submitted by the facility, on 08/15/2023 R1 was observed to be disoriented and confused. R1’s perception of time, date and location was not correct. When engaged in a conversation, R1 uttered inappropriate words and other incomprehensible words. The report stated that R1’s primary care physician was contacted, and the facility staff were instructed to send R1 to the hospital. R1 was admitted to St. Joseph’s hospital. The report listed the person(s) who observed the incident as the Facility Manager, Executive Director, and the Administrator. The report did not mention R1’s allegation against S1.
Continues on page 2 LIC 9099C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230821084701

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/03/2024

NARRATIVE

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The investigation revealed it was initially reported that on 08/15/2023, R1 alleged they were sexually assaulted by S1. It was reported that R1 alleged S1 had been sexually molesting them for approximately two years. R1 alleged S1 would touch R1’s private area (vagina) and that S1 would also make R1 touch S1’s private area. During the course of the Department’s investigation, R1 maintained their claim that S1 sexually assaulted R1. However, there were inconsistencies in R1’s disclosure of the sexual assault as R1 was now claiming S1 entered R1’s room and got on top of R1 while R1 was naked attempting to engage in sexual intercourse with R1. R1 stated they kicked S1 in the groin, and S1 stopped. R1 also disclosed that they would willingly perform oral sex on S1, because that is what R1 “liked to do from time to time.” During the interview with R1, R1 made other statements regarding their hobbies and daily activities which were later learned not to be true. R1 disclosed that they have a “garden” at the facility in which they grow various flowers. However, the facility Administrator later verified R1 did not have a garden at the facility. During the IB investigator’s visit to the facility, they did not observe a garden on the premises. Although R1 has never been diagnosed with Dementia or Alzheimer’s Disease, it was disclosed by the facility Administrator that R1 had recently begun smoking marijuana and drinking alcohol, along with taking their regular medication. As a result, a mild cognitive impairment was noticed with R1. During the Department’s investigation, S1 was also interviewed and denied any sexual abuse of R1. S1 claimed they only interacted with R1 on one occasion (approximately a year ago) when S1 and another staff member S2 cleaned and changed R1’s diaper and clothes after R1 defecated on themself in the bathroom. During the investigation, S2 was also interviewed and acknowledged assisting S1 with R1 after R1 had an accident in R1’s bathroom approximately a year ago. S2 stated they did not observe S1 touch R1 inappropriately.

Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the above allegation. Therefore, the allegation “Sexual Abuse – A facility resident was sexually assaulted by a facility staff member” is deemed Unsubstantiated at this time.

Exit interview, and a copy of the report was given.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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