197608401-3-15-2022-28-AS-SCOL-CDESMU-20220412140030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 03/15/2022
Date Signed: 03/15/2022 02:43:22 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
03/10/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220310140032

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: 55	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Peter Babaian		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident did not receive proper room change notice

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Peter Babaian and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Peter Babaian, Assistant Administrator Alice Nazarian, Staff 1 (S1) and Residents 1-5 (R1-5). LPA requested and received copies of Staff and Resident Rosters. LPA reviewed R1's file and obtained copies the following documents: Admission Agreement, Resident Appraisal dated 1/1/21, Identification and Emergency Information dated 3/5/21, Physician's Report for Residential Care Facilities for the Elderly (RCFE) LIC602A dated 5/19/21, Appraisal/ Needs and Services Plan dated 1/1/21 and 1/1/22, Two letters addressed to R1 dated 3/10/22 and 3/15/22, Unusual Incident/ Injury Report LIC624 dated 2/28/22 and 3/25/21. LPA also conducted a tour of facility which included observations of common areas, lobby, Resident Cottage 1511 and bathroom.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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 3

Control Number 28-AS-20220310140032

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: 03/15/2022

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

Investigation revealed the following: Regarding allegation, Resident did not receive proper room change notice, it is alleged that facility resident received a letter on 3/10/22 informing them that they will be relocated to another room in the facility in a week. It is alleged that the relocation is not due to any emergency. It is also alleged that the facility changed the notice of relocation from one week to 30 days due to resident's request for proper notice and resident personal rights. It is also alleged that facility administrator told resident that if anything happens in the 30 days the resident would be sued. Interview conducted with Administrator Babaian revealed that R1's physical condition has recently severely declined. He stated that R1 has been observed to have a strong limp and due to that R1 has to hold on to the walls while walking around the facility. He stated that R1 fell on 2/28/22 while coming in to the facility. Administrator stated that facility nurse offered R1 a walker which the resident took and has been see to use while in the facility but does not use when going out of the facility. Administrator stated that R1 refuses to be reassessed by the facility doctor and insisted on going to their doctor. Administrator stated that R1 was provided with a Physician's Report for Residential Care Facilities for the Elderly (RCFE) LIC602A so that they can take to their doctor for completion but has not received a copy from R1 yet. Administrator denied telling R1 that they will be sued. Administrator stated that due to R1's recent change in physical condition it is highly unlikely that R1 would be able to physically respond or take appropriate action in relation to an emergency such as a fire danger which is the reason that the decision was made to move R1 to a non ambulatory room in the facility and proper notice was given to R1. Administrator stated that R1 was given a one week notice of room change but due to R1 complaining the notice was updated to 30 days which is proper notice to resident for a room change. Notice was served to R1 on 3/15/22 and change is to take effect on 4/15/22. Interview with S1 revealed that they have recently observed R1's physical condition to change drastically. S1 stated that for the past 6 months a change in the physical condition of R1 has been observed but the resident continuously declines to be seen by the facility doctor. S1 stated that R1's condition has worsened within the last four weeks and on 2/28/22 resident fell while coming into the facility. S1 offered R1 a walker which they use around the facility but do not want to use when going out. S1 stated that when R1 is not using the walker they hold on to the walls for balance. Interview with R1 revealed that they believe the facility is making up that they need a walker so that they can move resident out of their room which they have lived in for over 30 years. R1 also stated that they use the walker only when out of the facility and stated that they do not need the walker but only use it for comfort. Interviews with R2-5 revealed that they are properly notified of any changes by facility and stated that they do not have any concerns. LPA review of R1's Resident Appraisal revealed that R1 refuses to be seen by facility doctor and recent observation of resident is poor balance. LPA review of R1's Appraisal/ Needs and Services

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220310140032

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: 03/15/2022

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

Plan dated 1/1/22 revealed that poor balance has been observed and R1 has been offered a walker or cane due to fall risk but R1 refuses to use them. During interview with R1, LPA observed resident to not be able to stand without finding balance, observed resident to hold on to hallway walls while walking through facility hallway and also try to hold on to a bush to find balance during interview. LPA observed a walker in R1's room.

Based on interviews conducted with facility staff, facility residents and LPA observations, there was not enough supportive evidence to concur with the reported allegation.

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

Exit interview held. A copy of the report was provided to Administrator Peter Babaian.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3