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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 07/15/2022
Date Signed: 07/15/2022 02:41:03 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
03/19/2021 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210319083138
FACILITY NAME:VICTOR ROYALE, LLCFACILITY NUMBER:
197608401
ADMINISTRATOR:PETER BABAIANFACILITY TYPE:
740
ADDRESS:120 E. LAUREL STREETTELEPHONE:
(818) 243-7442
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:60CENSUS: DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator - Peter BabianTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not make the phone available frequently.

Staff did not provide adequate first aid.

Staff do not intervene when resident is bullied.

Admission Agreement is not adhered to
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Calderon initiated a subsequent unannounced complaint investigation for the allegations listed above. LPA met with Administrator Peter Babian and explained the purpose of the visit which was to deliver investigation findings.

On 03/24/21, LPA Tao conducted a telephonic initial visit, during visit, LPA interviewed Staff #1, Staff #2, Staff # 3, and Resident #1 and obtained copies of resident roster and staff schedule. LPA Tao requested copies of the following documents, Resident#1’s (R1) Face sheet, physician report, admission agreement, appraisal -needs and services plan, incident reports for March 2021 related to R1, training logs regarding residents’ rights, wound care, first aid, residents being bullied and staff #1’s &#2 first aid certificates.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
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 4
Control Number 28-AS-20210319083138
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: 07/15/2022
NARRATIVE
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On 07/14/22, LPA Calderon toured physical plant with Staff Nazaran and observed working telephones that are accessible to residents and fully stocked first aid kits that are not accessible to residents. LPA interviewed residents #3-7 (R3-7), and interviewed Staff #1,#4-8 (S1, S4-S8).

On 07/15/22, LPA Calderon attempted to interview S3, S9 and R2 and received S3 and S4 first aid training .

Regarding the allegation " Staff do not make the phone available frequently " LPA obtained the telephone policy and toured and observed three (3) different areas in the facility that have telephone that are accessible for residents to use. Interview with 5 of 7 residents indicated that telephone are available for resident use and staff do not restrict resident use unless resident are waiting to use the telephone. Interviews with 7 of 9 staff indicate that telephone are available for resident use and staff do not restrict the resident from using the telephone. It was also revealed that R1 was informed by staff that if other residents needs to use the telephone, for R1 to limit the time spent on the telephone call in order for other residents to have access. 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.



Regarding the allegation "Staff did not provide adequate first aid " On todays, LPA Calderon toured the physical plant and observed First Aid Kits were located Med Room and Front Desk and were fully stocked. Interviews with 5 of 7 residents revealed that staff provide residents with first aid as needed. Interviews with 7 of 9 staff revealed the first aid kits are fully stocked and staff are trained to provide first aid to residents. LPA Calderon reviewed 03/15/21 incident report and police report #21-3417. Per the incident report, on 03/15/21, an incident occurred where R1 sustained a scratch due to an altercation with R2 and R1 called local law enforcement with staff being aware. Per the police report # 21-3417, Staff 3 provided R1 with first aid and did not observe any serious injury and document the incident. Per the police report, the officer spoke with R1 at the facility and offered medical treatment which R1 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 28-AS-20210319083138
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: 07/15/2022
NARRATIVE
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Regarding the allegation: Staff do not intervene when resident is bullied. Per the details, it was alleged that a resident followed another resident in the facility to intimidate the resident and a resident pushed a resident to the floor in front of staff who did not intervene. Interviews with 3 of 7 residents revealed resident are insulted or bullied by other residents, however, staff were not present and were not made aware at the time of the incident. Interviews with 3 of 7 residents revealed they are not aware of residents being bullied by other residents. Interview conducted with R1 revealed that staff were not present during the 03/15/21 incident between R1 and R2. R1 also indicated that other resident bullied R1 in the facility. On 03/24/21, LPA Tao made an attempt to interview R2 and on 07/14/22 & 07/15/22, LPA Calderon attempted to interview R2, however R2 was not available at the time. Interviews with 7 of 9 staff revealed that staff do not recall an incident where R1 was pushed to the floor by a resident and staff did not intervene. The investigation revealed that staff intervene if they see a resident is being bullied or needs assistance and staff were not aware of the 03/15/21 incident between R1 and R2. The investigation did not reveal any evidence to support that staff do not assist residents who are being bullied. 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20210319083138
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: 07/15/2022
NARRATIVE
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Regarding the allegation: Admission Agreement is not adhered to. It was alleged that the facility is not following the admission agreement, residents are smoking inside the facility, transportation schedule for shopping is not being provided to residents, no planned activities are being conducted, residents do not get mail and facility is not safe. Interviews with 5 of 7 residents revealed residents were not aware of staff not adhering to the admission agreement and staff follow the admission agreement. 1 of 7 residents was not available for interview. Residents states the facility has an outside are for smoking and the facility does not allow resident to smoke inside the facility, staff give resident their mail, staff assist with transportation and provide residents with activities. Interviews 1 of 7 residents stated that staff do not follow the admission agreement. Interviews with 7 and 9 staff revealed that staff follow the admission agreement. Staff stated resident have outside are designated for smoking and resident are not allowed to smoke inside the facility. Staff have observed residents smoking in the facility and intervene by directing the residents to smoke outside. Staff state the residents are provided with mail and do not withhold the mail. Facility has a full-time activities director who schedules activies for resident on a daily basis and the Monthly Activities Calendar is posted in a common area of the facility for resident to view. Staff state that residents are able to schedule transportation for shopping with staff as needed. Staff state the facility is safe, staff check on residents as needed. LPA Calderon toured the facility on 07/14/22 and did not observe the facility to have any health and safety issues. The investigation did not reveal any evidence to support that staff are not adhering the to the admissions agreement. 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 with Administrator Peter Babian. A copy of this report along with the appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4