197608401-10-13-2022-28-AS-TVAO-CM3PDU-20221213101401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:13:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/06/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221006090702

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:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alise Nazarian, Assistant Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff failed to address resident hitting another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA met with Assistant Administrator, Alise Nazarian, and explained the purpose of the visit.

LPA obtained copies of the staff roster, resident roster, staff training log, and documents pertaining to Resident #1. LPA interviewed the Administrator, 4 Staff, and 6 Residents.

Regarding allegation – Staff failed to address resident hitting another resident. It is alleged that the Administrator nor staff checked on the residents after Resident #1 (R-1) hit Resident #2 (R-2). Per the Administrator, he was not aware of the incident until yesterday when it was reported by the staff. According to staff interviews, they believe the incident was or should be reported by the staff on duty who has/have knowledge about it right away to the Administrator. However, this was not done. All 4 Staff heard about the incident the following day from other residents, but assumed it was reported to the Administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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-20221006090702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 10/13/2022

NARRATIVE

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3 out of 4 Staff stated that R-1 can be verbally aggressive towards staff and residents and had agreements with other residents. They said that the incidents involving R-1 were reported to the Administrator but not sure if anything was done about them.

Administrator Babaian acknowledged that R-1 has difficulty getting along with some Staff and some residents. R-1 can be loud and verbal which may appear to be disruptive in the facility. He had spoken to R-1 about the tone of voice being used and given verbal warnings. No written warnings had been issued yet until the Administrator completes his investigation of this incident.

LPA interviewed 6 residents today. R-1 denied getting aggressive or hitting R-2 sometime last week. R-2 reported that resident was hit in the face by R-1 last Thursday. 2 residents witnessed the incident and saw R-1 swinging at R-2 repeatedly, but was not sure if R-2 was hit in the face. They stated the staff on duty heard the commotion but did not intervene nor checked on the residents. Some of the staff and residents do not feel safe with R-1’s increase of aggressive behavior.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221006090702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 10/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/20/2022 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirement - General (d) All personnel shall be given on the job training...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall conduct a staff training to ensure the proper protocol to take when they hear or witness a resident on resident altercation. This log shall be submitted to LPA by POC due date 10/20/22.
	8 9 10 11 12 13 14	Based on interviews, Staff did not report R-1's aggressive behavior to the Administrator which poses a potential health and safety and personal rights to residents in care.	8 9 10 11 12 13 14
CCR	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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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