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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 12/23/2021
Date Signed: 12/24/2021 08:54:00 AM

Document Has Been Signed on 12/24/2021 08:54 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
CCLD Regional Office, 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: 76DATE:
12/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lori McKayTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20211221162023.

During the file review, the LPAs audited the file for Staff #1 (S1) and noted that S1 was not associated to the facility during the beginning of LPAs' visit to the facility starting at 11:15 a.m. After reviewing the Caregiver Background Check System, it was noted that S1 has background check clearance, but was not associated to the facility until 12/23/2021 at 1:25 p.m. Based on the file review, it appears S1 started working for this facility on or about 11/16/2021 when S1 had In-Service training. A review of the facility staff schedule for the week of 12/20/2021 shows S1 was scheduled as a resident aide for 12/21/2021 - 12/24/2021. In addition, S1 was missing health screening documentation.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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 12/24/2021 08:54 AM - It Cannot Be Edited


Created By: Teresa Camara On 12/23/2021 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
8735(e)(2)

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87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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S1 was associated to the facility by the facility management during LPAs visit.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above, as S1 was not associated to the facility until 12/23/21, however S1 has been working at the facility since approximately 11/16/21, which which poses an immediate health and safety risk to residents in care.
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Type A
12/30/2021
Section Cited
CCR87411(f)

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87411(f) Personnel Requirements - General. All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months
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Administrator will remove S1 from the schedule until a health screening is obtained. Administrator will provide a copy of S1's health screening to CCL on or before 12/30/21.
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prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...This requirement is not met as evidenced by: S1 was missing a health screening, which poses an immediate 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021


LIC809 (FAS) - (06/04)
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