197608129-5-10-2021-29-AS-KBUY-C4FTV2-20210629150314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 05/10/2021
Date Signed: 05/10/2021 03:18:16 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
03/23/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20210323094208

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:	02:30 PM
MET WITH:	Lito Vitug - Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff do not prevent residents from engaging in verbal altercations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically at 2:30pm with Lito Vitug , the Executive Director.

During the course of the investigation, LPA conducted a physical plant tour virtually on 3/24/2021. 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 since 2/23/2021 , residents can be heard engaging in verbal altercations on multiple occasions and staff are not preventing these incidents.

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-20210323094208

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 through interviews with (13) residents and (9) staff revealed that only Resident 1 (R1) and Resident 2 (R2) have been involved in verbal altercations since 2/23/2021. During that period, R1 and R2 had rooms next to each other. As of 3/25/2021, both residents have since been relocated to rooms away from each other. Interviews with residents also revealed that most believed staff handled the altercations properly and without violating any resident’s personal rights. Additionally since the relocation of R1 and R2 , most residents have not witnessed any verbal altercations between R1 and R2 or any other residents. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that facility staff do not prevent residents from engaging in verbal altercations. Therefore the above allegation is 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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