197608401-6-21-2022-28-AS-LHIS-CGXUVS-20220803155538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:13:39 PM

Substantiated

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
06/15/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20220615161924

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:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Administrator Peter Babaian		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff does not post Ombudsman poster.

INVESTIGATION FINDINGS:

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On 6/21/22 at 10:05 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Peter Babaian(Administrator) and explained the purpose of the visit.

Investigation consisted of the following: During today’s visit LPA toured the facility with assistant administrator, obtained resident/ staff roster, remodeling invoice dated 10/26/2021- 2/10/22 and photo of remodeling sign posted outside dining room. LPA interviewed residents R1- R7. LPA Interviewed administrator, Staff S1- S3.

The investigation reveals the following: In regard to "Staff does not post Ombudsman poster.", it is alleged that the facility does not have the Ombudsman poster posted in the facility. During the visit LPA toured the facility and was not able to locate the Ombudsman poster. LPA observed a signed posted by dining room confirming remolding started August 16th, 2021. Administrator confirmed poster was removed during facility remodeling on March or April of 2022.

Report Continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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-20220615161924

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: 06/21/2022

NARRATIVE

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Administrator also confirmed the remodeling finished last Wednesday 6/15/22 and has ordered replacement posters. Administrator affirmed required postings will be completed next Friday 7/1/22. 7/7 residents stated that they have seen the Ombudsman poster a year ago or they have never seen the poster. 3/3 Staff interviews confirmed the Ombudsman poster was taken down due to remodeling. 1/3 staff stated postings was removed about a year ago while 2/3 staff stated they are unsure of the date the postings was removed.

Based on LPA observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with administrator/ Appeal Rights Provided / A Copy of the Report Issued

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220615161924

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: 06/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/01/2022 Section Cited CCR 87468.2(a)(10)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) residents in…shall have all of the following personal rights: ... The licensee shall post the telephone numbers and addresses for the local offices of the … ombudsman program,... This requirement is not met as evidenced by	1 2 3 4 5 6 7	Licensee shall ensure the required postings are posted in a location that is easily accesible to residents and provide picture proof of the required postings to LPA by POC date.
	8 9 10 11 12 13 14	Based on observations, interviews the licensee did not comply with the section cited above by not having the Obudsman poster posted, which poses an pontiential health, safety, or Personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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