197608401-9-1-2022-28-AS-MVAO-CJ2PWL-20220907114054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:54:26 AM

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
01/10/2022 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20220110081057

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:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Peter Babaian		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not properly reappraise the resident.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2) and was later met by Administrator (A1) Peter Babaian. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of today's visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day visit was conducted by LPA Nicol Wesley on 01/19/22.

LPA/RA Ceniceros interviewed (between 9:50 a.m - 10:15 a.m.) two (2) staff members and one (1) resident in care. LPA/RA reviewed and requested pertinent documentation: Admissions Agreement (updated 01/31/13) Emergency I.D. & Information (updated 04/22/22), Physician's Report (dated 04/19/22), Appraisal/Needs & Services Plan (updated 01/01/21) for Resident #1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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 2

Control Number 28-AS-20220110081057

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: 09/01/2022

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

Regarding Allegation #1: this investigation revealed that Resident #1 is ambulatory with reduced mobility currently which is due to severe right-hip arthritis. A review of the resident's Physician's Report (dated 04/19/22) by the primary care physician (PCP) documents that Resident #1's diagnosis are "none" for first and secondary diagnosis. Interviews conducted corroborated that Resident #1 is walking around without any assistance but poor balance is noticeable and the resident is using a walker. A review of Resident #1's Appraisal/Needs & Services plan (dated 01/01/21) documented that Resident #1 has seen a specialist for right-hip arthritis and is awaiting surgery.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of OTHER: Facility did not properly reappraise the resident is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Administrator Administrator (Peter Babaian).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2