197608129-3-19-2025-29-AS-KLOZ-DF426Y-20250324170754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 03/19/2025
Date Signed: 03/19/2025 04:33:06 PM

Substantiated

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
03/18/2025 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20250318150354

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: 88	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Riza Vitug/Joselito Vitug		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff are not addressing pests at the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced 10-day complaint visit for above allegation. Upon arrival, LPA met with Assistant Administrator Riza Vitug and explained the reason for the visit.

During todays visit, starting at 12:15 p.m., the LPA conducted a physical plant tour, inspected the kitchen, conducted one (1) witness, eight (8) staff and ten (10) resident interviews, and conducted a file review.

Report continued on LIC9099-C, 2ND PAGE.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

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-20250318150354

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: 03/19/2025

NARRATIVE

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On the allegation that, “Staff are not addressing pests at the facility”; it is the concern of the reporting party that the facility kitchen is infested with cockroaches even though the facility receives pest control services. It was further reported that there were three live adult German cockroaches on the kitchen floor, under the ice machine, one live Nymph German cockroach on the kitchen wall, and approximately ten dead cockroaches on the floor, throughout the kitchen. Three photos were submitted as evidence. To investigate the allegation, the LPA inspected the kitchen, conduced resident and staff interviews, conducted a file review and requested records of the facility’s ongoing pest control services and maintenance records.

Photos submitted were reported to be of the cockroaches in the kitchen at the facility. Photo #1 shows a close-up view of the floor where it meets the wall. You can see dirt, debris, a black cable, along with a metallic structure. Additionally, there is a cockroach in the center of the image, positioned on the floor, close to the black cable resting on the floor. Photo #2 shows a textured, patterned surface, with a small insect on it that appears to be a cockroach nymph or another small pest, with long antennae extending outward. Photo #3 shows a section of a floor, with noticeable dirt, debris, cockroaches, droppings and small objects scattered around. There are also signs of pest activity, as evidence by what appear to be multiple cockroaches and black droppings in the photo.

At 12:25 p.m. the LPA observed a dead cockroach on the floor beneath a table next to the ice machine while inspecting the kitchen. One (1) out of ten (10) residents and one (1) witness revealed that they have observed cockroaches in the residents’ rooms, however the witness revealed that when they notify staff, they will put the residents’ room on the list to spray and take care of it. Five (5) out of eight (8) Staff interviews revealed that they have observed cockroaches in the kitchen and in residents’ rooms from time to time, however pest control services are performed monthly and as needed. Interview with the Assistant Administrator revealed that a health inspector had been at the facility on 03/17/25 and recommended for pest control services to be conducted, however the Assistant Administrator was not aware of the reasons why the services were recommended and revealed that a pest control company services the facility every two (2) weeks. The Assistant Administrator provided the LPA with documentation of the scheduled appointment made with Pest Rangers for 03/17/25, following treatment appointment on 04/01/2025, and invoices for services provided by them on 01/08/25, 02/04/25, and 03/04/25.

Report will LIC9099-C, 3rd page.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20250318150354

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: 03/19/2025

NARRATIVE

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Furthermore, file review revealed that the Administrator submitted an Incident Report (LIC624) reporting that on 03/17/2025, an LA County Dept. of Public Health Inspector conducted a physical plant inspection of the facility and found evidence of bug infestation in the kitchen. Additionally, the Administrator informed the inspector that a Pest Control Maintenance Service was conducted two weeks prior and provided copy of the invoice. Based on the information obtained and interviews there is sufficient evidence to support the allegation occurred; therefore, the above allegation is deemed Substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Assistant Administrator was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20250318150354

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/28/2025 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	General Food Service Requirements (b)The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure kitchen will be thoroughly cleaned and sanitized, will submit a plan for the next 3 months to ensure all regular and preventive professional treatments are taken. Administrator will submit proof to CCL by 03/28/2024.
	8 9 10 11 12 13 14	Based on LPA and witness observation, interviews, file review and pictures obtained, the licensee did not comply with the section cited above as roaches were observed in kitchen areas. This poses a potentail health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

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