197608401-7-20-2021-28-AS-LHIS-C76UT8-20210924155131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:16:33 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
07/13/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210713094059

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: 51	DATE:	07/20/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alise Nazarian, Assistant Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not assist resident with receiving medication.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cynthia Chan and Nune Margaryan conducted a complaint investigation for the allegation listed above. LPAs met with Alise Nazarian, Assistant Administrator and explained the purpose of the visit.

LPAs interviewed the Administrator, Assistant Administrator, 3 Staff, and 6 Residents. LPAs obtained a copy of the Staff and Resident rosters, and documents for Resident #1 (R1): Face Sheet, Preplacement Appraisal Information, Physican's Report, Appraisal/Needs and Services Plan, Medication log from January - June 2021, and facility notes. Resident #1 has not returned to the facility since 6/11/21 and was not interviewed.

In regards to allegation - Staff did not assist resident with receiving medication. According to interviews with the Administrator, Assistant Administrator, and 1 Staff, they were aware of Resident #1's (R1) refusal of medication. Staff interviewed noticed that R1's behavior was becoming more agressive than usual and the refusal of medications may have attributed to the behavior in the beginning of June. (Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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-20210713094059

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: 07/20/2021

NARRATIVE

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The other staff interviewed does not pass out medication so staff did not know if R1 was taking medications or not. Staff who passed medication to R1 indicated they often encouraged R1 to take the medication while observing R1 to ensure that the pills were swallowed. R1's medication refusal began as early as 6/5/21 for some of the medications as documented on the Medication Administration Record (MAR) logs. At the same time, staff started noticing the increased aggressive behaviors from R1. Staff stated they immediately informed the LVN and Assistant Administrator. Per Assistant Administrator, the doctor was contacted when R1 started refusing to take the medications. She also called to PET Team to evaluate R1's aggressive behavior when it occurred more frequently, however, the team determined R1 did not qualify as a danger to oneself or others so R1 remained at the facility. The next day, R1 continued to refuse medication and the behavior continued, which led to staff contacting the police. The police came to the facility and placed R1 on a 5150 hold. LPA interviewed R1's son who indicated that the facility called to informed him that R1 refused to take some of the medications which was possibly the cause of R1's outbursts. He was also aware that the physician was contacted and understood that the facility cannot force the medication on residents. It was determined that staff assisted R1 with medication and also took the appropriate steps when medication were refused.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with the Administrator, Peter Babaian, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

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