197608129-8-27-2021-29-AS-DPEA-C89QXT-20211029123403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:20:54 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
07/17/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200717151654

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: 71	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lori McKay - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents bathroom is not wheelchair accessible

Lack of supervision resulting in resident wandering into another residents room

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation for the above allegation. Upon arrival LPA met with Lori McKay Administrator and explained the reason for the visit.

During the course of the investigation, LPA conducted a physical plant tour virtually on 7/23/2020. On 5/24/2021, LPA conducted interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

It was alleged that , Residents bathroom is not wheelchair accessible. During physical plant, LPA observed Resident 1's(R1s) maneuver their wheel chair into their private bathroom. LPA also observed R1 maneuver their wheelchair into a bathroom in the hallways that is designated for all residents to use. LPAs interview with Administrator revealed that R1 previously lived in a different unit with a smaller bathroom, then was relocated to the unit they're in now, which is the biggest unit in the building and has the largest bathroom.

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: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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 2

Control Number 29-AS-20200717151654

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: 08/27/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

continued from 9099

Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that residents bathroom is not wheelchair accessible. Therefore the above allegation is UNSUBSTANTIATED at this time.

It was alleged that , lack of supervision resulting in resident wandering into another residents room. LPA interview with R1 revealed that another resident wandered into their room only (1) time and it has not happened again. R1 stated that the resident peeked their head in. R1 does not remember the name or when it exactly happened. LPA interview with (13) Residents revealed that all did not express any immediate or major concerns of other residents wandering into their bedroom and all have not witnessed any resident enter their bedroom without their consent. LPA interview with Administrator revealed that there is always at least (2) staff on duty making rounds as well as cleaning staff continuously cleaning common areas and various units. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that lack of supervision resulting in resident wandering into another residents room. Therefore the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2