197608401-9-15-2021-28-AS-MVAO-C74NT5-20210922104409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:48:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20200819155029

FACILITY NAME:	VICTOR ROYALE, LLC		FACILITY NUMBER:	197608401
ADMINISTRATOR:	PETER BABAIAN		FACILITY TYPE:	740
ADDRESS:	120 E. LAUREL STREET		TELEPHONE:	(818) 243-7442
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	60	CENSUS: 54	DATE:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Administrator, Peter Babaian		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff engaged in a physical altercation with a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint investigation visit in regards to the allegation above. LPA was greeted by Peter Babaian and Alise Nazarian and explained the reason for todays visit.

The investigation consisted of the following: On 8/27/2020, LPA Almaraz conducted telephonic interviews with Administrator, Staff #1-4, and Residents #1-4. LPA requested copies of: Staff and Resident Roster, Police report number and Incident Reports. LPA also requested video footage of the incident. On 9/15/2021, LPA requested files for Staff #2, Resident #1 and #5. LPA also attempted to interviewed Resident #5 but the resident no longer lives at the facility.

The investigation revealed the following: Based on interviews conducted, on 8/19/2020, Staff #2 was near a reception area when Resident #1 came by and was standing near the area. Staff #2 stated that Resident #1 was trying to enter the back of the reception area and told Resident #1, resident could not go behind the counter and had to move.
(Continued on an LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 28-AS-20200819155029

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/22/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... .	1 2 3 4 5 6 7	Adminstrator will conduct Elder Abuse/Personal Rights training with all staff. Administrator stated he will have a meeting with Staff #2 and give the staff a written warning. Administrator also conducted training on 10/2020 and will send all documentation to LPA
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Staff #1 grabbed Resident #1 by the arm and shoved the resident away from the reception area causing the resident to hit the table/dresser and it falling towards the resident. Staff #1 also grabbed a walking cane from Resident #4 and swung the cane towards Resident #5.	8 9 10 11 12 13 14	Administrator will send proof of training conducted for this month, and from 10/2020 along with written warning issued to Staff #2.
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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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200819155029

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 09/15/2021

NARRATIVE

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Per Staff #2, the phone started ringing and Staff#2 tried to go behind the counter and Resident #1 was blocking Staff #2. Staff #2 stated it never touched Resident #1, but when Staff #2 tried to go in the reception area Staff #2 stated Resident #5 attacked Staff #2. Video footage showed Staff #2 walking behind Resident #1 and doing hand gestures to Resident #1 to move away and go away from the area. The video shows Staff #2 does this repeatedly until Resident #1 moved to a corner by the entrance to the reception area . When the resident was in the corner, Staff #2 grabbed Resident #1 by the arm and shoved the resident away from the corner causing the resident to bump into a piece of furniture which appears to be a table/dresser with a vase of flowers on top. The table/dresser and flower vase fell towards Resident #1 and caused the resident to lose balance and walk backwards till the resident dropped on one knee. The video shows Resident #5 come and push Staff #2, two times, walking towards Staff #2 and causing Staff #2 to walk backwards. Staff #2 then grabbed Resident #4's walking cane and swung the cane towards Resident #5. Resident #5 grabbed it while the cane was aim at Resident #5 and took it away from Staff #2. Resident #4 stated that Staff #2 grabbed the cane in an attempt to hit Resident #5. Administrator stated the Glendale Police Department was contacted and a police report was filed.

Based on video observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D

An exit Interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights were provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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