197608401-6-21-2022-28-AS-FFIS-CHW7KB-20220902214341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:09:55 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
06/16/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220616144854

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:	11:31 AM
MET WITH:	Peter Babaian - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents are not allowed to participate in their appraisal needs and services plan.

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 Babaian Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6), administrator, staff #2(S2),#3(S3),#4(S4). Requested copies of identification and emergency information sheet, physician's report, appraisal/needs and service plan for R1,R2,R3,R4,R5 and assisted living waiver(ALW) individual service plan (ISP) for R1 from resident's files.

The investigation revealed the following: Regarding allegation: Residents are not allowed to participate in their appraisal needs and services plan. It is alleged staff have not included resident in decision making regarding appraisal needs and service care plan.
(CONTINUED ON 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: 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)

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Control Number 28-AS-20220616144854

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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Interviews with residents revealed 3 out of 6 residents stated not being able to recall whether or not participated in the appraisal needs and care plan process. 2 out of 6 residents stated to have not been a part of the appraisal needs and care plan. 1 out of 6 residents stated to not need care and not caring for a plan. Administrator stated that three staff meet with residents in the activity area and review the appraisal needs and care plan with residents, unless the residents are under ALW program, then social worker (SW) and nurse (LVN) meets with residents and after assistant administrator is provided a copy. 3 out of 3 staff interview stated to review the appraisal needs and care plan with the residents in the activity area as often as needed, per changes in condition or changes in care for residents needs. Documents review revealed 4 out of 5 appraisal needs and care plan were signed and dated 1/1/22 and 1 out of 5 had noted "resident refused to sign" and dated 1/1/22. ISP reviewed for R1 was signed and dated on 3/4/22. Phys cian's report reviewed noted 5 out of 6 residents need some assistance with a few daily living activities and 1 resident does not require any assistance. 6 out of 6 residents are self responsible allowing them to make decisions for themselves. Staff payroll list for 1/1/22 lists the staff responsible for appraisal needs and care plan worked on the day the appraisal needs and care plan were signed.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are 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: 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)

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