197608401-3-16-2023-28-AS-NMAN-CSS256-20230613170502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:24:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 28-AS-20230104081859

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: 52	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	10:41 AM
MET WITH:	Alise Nazarian		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Resident caused injury to another resident due to staff's lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at 10:35 am. Upon arrival LPA Smith observed Resident #1 (R1) as they headed from residential bungalow area to the main facility. LPA observed R1 grabbing hold of a parked vehicle for balance and then hold side of wall as they entered the facility. LPA met with Administrator at approximately 10:45 am and disclosed purpose of visit.

During initial visit on 01/09/2023, LPA Smith conducted tour of physical plant, requested documents relevant to the investigation, conducted interviews with staff and interviewed R1.

Resident caused injury to another resident due to staff's lack of supervision
It was alleged that a resident caused injury to another resident due to staff's slack of supervision. Interviews with ten (10) out of ten (10) staff reveal that there is staff supervising dinning areas and other common areas within the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: (818) 307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20230104081859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 03/16/2023

NARRATIVE

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(Cont. From 9099)

Four (4) out of ten (10) staff reveal when meals are being served the food servers are monitoring the dining area. Interviews with five (5) out of (5) residents revealed that they have supervision in dining room and in common areas. Interview with R1 revealed that they sometimes see staff in the dining room but not always. R1 also revealed that even though they use a walker they are ambulatory and can balance with arms out to the side. Interview with Resident #2 (R2) they have not pushed or harmed R1. R2 states tapped R1 on arm to request room for their walker and then R1 lost balanced and fell as R1 does not use their walker all the time. R2 states they have Multiple Sclerosis (MS) and need to have room when using their seated walker. Physician’s reports reveal R1 has severe hip arthritis and poor balance directly related to their hip arthritis and R2 physicians report reveal R2 has MS.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: (818) 307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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