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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:49:43 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
08/04/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220804131712
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: 55DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator/S-1TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility does not allow residents to wash their clothing
Residents bathroom emergency system does not have a pull cord
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with S-1 and discussed the purpose of today's visit.

During this investatigation, LPA obtained the staff roster and resident roster. LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). LPA also conducted a tour.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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 5
Control Number 28-AS-20220804131712
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: 08/11/2022
NARRATIVE
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Allegation: Facility does not allow residents to wash their clothing. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). (3) staff out of (3) indicated they have not received any requests from residents requesting to wash their own clothes. (5) out of (6) residents indicated the facility staff wash their clothing and that they have not requested staff to allow them (residents) wash their (residents) own clothing. Staff and resident interviews do not corroborate this allegation

Allegation: Residents bathroom emergency system does not have a pull cord.
During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). Staff interviews revealed, resident bathrooms have a signal system. Staff interviews also revealed that some of the signal systems function either by a cordless switch or a switch that has a cord integrated. Interviewed residents indicated they are aware as to how the signal switches and cords operate. LPA also toured the bathrooms, observed and tested the signal system switches. LPA also observed and tested the signal systems in random resident rooms. All tested signal systems were operable. Staff interviews, resident interviews and tour do not corroborate this allegation.

Although the allegation may have happened or is 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 conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/04/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220804131712

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: 55DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator/S-1TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not following COVID protocol
Facility does not maintain a comfortable temperature in resident's room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with S-1 and discussed the purpose of today's visit.

During this investatigation, LPA obtained the staff roster and resident roster. LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). LPA also conducted a tour.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220804131712
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: 08/11/2022
NARRATIVE
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Allegation: Facility is not following COVID protocol. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). LPA also conducted a tour. LPA observed COVID postings throughout the facility. Staff interviews revealed that residents are reminded to maintain social distancing. Interviewed staff also indicated meal times and social activities are staggered to ensure that social distancing is practiced. Staff indicated there are hand sanitizer stations throughout the facility and that there is ample PPE supplies (masks) available. Interviewed Residents indicated there are COVID postings throughout the facility, staff remind residents of social distancing, there are hand sanitizing stations throughout the facility. (5) out of (6) interviewed residents also indicated the staff provide face masks upon request. During LPA’s tour, LPA observed hand sanitizer stations throughout the premises. However, LPA observed all hand sanitizer stations to be empty in cottages 1511 and 1515. Based on facility tour, this allegation is corroborated.

Allegation: Facility does not maintain a comfortable temperature in resident's room. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident #6 (R-1 through R-6). (1) staff out of (3) indicated the indoor temperature on the cottage 1511 and 1515 at times feels hot. (4) out of (6) residents indicated the indoor temperature in cottage 1511 and 1515 feels hot. At approximately 11 A.M, LPA toured cottages 1511 and 1515. In cottage 1511, room#1, the room temperature measured 89.2* and in room #4 the temperature measured at 89.6*. LPA also observed resident rooms to have a small fan and some had air conditioning units on their windows. However, the indoor temperature exceeded Title 22 requirements.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220804131712
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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
HSC
1569.50(a)(3)
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The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California
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Administrator to ensure all hand sanitizer stations have hand sanitizer liquid at all times.

CORRECTED AT TIME OF VISIT.
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This standard is not met as evidence by: During facility tour, LPA observed all hand sanitizer stations to be empty in cottages 1511 and 1515.
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Type B
08/15/2022
Section Cited
CCR
87303(b)(2)
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Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.
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Administrator to provide a written plan as to how this deficiency will be rectified and how this facility will maintain indoor temperature comfortable as per 87303(b)(2) and provide this to LPA Irra by POC due date of 08/15/2022.
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This standard is not met as evidence by:

At approximately 11 A.M,, LPA toured cottages 1511 and 1515. In cottage 1511, room#1, the room temperature measured 89.2* and in room #4 the temperature measured at 89.6*. In cottage 1515, room #5, the temperature measured at 89.2*.
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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: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5