197608401-4-11-2022-28-AS-SCOL-CF8NV3-20220609104716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 04/11/2022
Date Signed: 04/11/2022 02:08:08 PM

Unsubstantiated

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
04/05/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220405121014

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:	04/11/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Peter Babaian - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident was not provided with a 30 day notice to change rooms

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Peter Barbaian and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested copies of staff/resident roster, Resident #1(R1) 30 day notice, admission agreeement, physician's report, appraisal needs and care plan, notices for room change. LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R3),#5(R5),#6(R6) administrator, staff #2(S2),#3(S3),#4(S4).

The investigation revealed the following: Regarding allegation; Resident was not provided with a 30 day notice to change rooms. It is alleged resident was not provided with a 30 day notice to change rooms.
(CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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-20220405121014

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: 04/11/2022

NARRATIVE

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Interviews with residents revealed the following 2 out of 6 residents have not move rooms, have not been requested, or requested to moved therefore do not know of the process. 2 out of 6 residents were not able to answer to questions due to cognitive skills. 1 out of 6 stated to have requested in writing to move rooms and move when a room was available and 1 out of 6 stated that a copy of notice was not provided when provided with the notice. Interviews with staff revealed 2 out 4 staff interviewed stated residents are notify prior to room change and if residents agree change happens. 2 out 4 staff stated that R1 was given a letter to notify of room change due to resident's changes in physical health. Administrator also stated resident was given a copy of 30 day on 3/15/22, however did not obtain a signature from R1 as a result on 4/5/22 provided another letter reinitiating the 30 days. Administrator stated R1 refuses to be assess by a physician to note change in physical condition and that the reason for the room is to ensure R1's safety as the cottage is licensed for non-ambulatory residents and staff have notice R1 becoming a fall risk and want to prevent further falls. LPA reviewed the following documents for R1's Admission agreement signed on 1/31/13. Appraisal Needs and Service Plan dated 2/23/22 notes resident refuses assistance and notes physical changes. Emergency and Identification Information form notes R1 is self-responsible. Letter to notify resident of room change dated 3/10/22 states change is due to changes in physical health and moved is to take place within a week. Second letter provided on 3/15/22 states the same reason and the move is planned for 4/15/22, (refer to complaint #28-AS-20220310140032). Third letter signed by R1 on 4/5/22 has updated move date to May 5th, 2022. LPA Flores advice administrator to ensure R1 is reassess by a primary physician and that facility contacts physician with current concerns, and changes in condition to ensure of proper assessment.

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

Exit interview was conducted with Peter Babaian Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

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