197608401-3-6-2023-28-AS-TVAO-CQ8KMA-20230324080107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 03/06/2023
Date Signed: 03/06/2023 03:55:43 PM

Unsubstantiated

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
06/14/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210614155032

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:	03/06/2023
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Administrator Peter		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident causing injury to another resident in care.
Resident has access to a hazardous item.
Staff did not safeguard resident's personal belongings.
Resident does not have access to the bathroom.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit stemming from initial 10-day complaint visit conducted on 06/22/2021, by LPA’s Luis Mora and David Sicairos. LPA Ramirez met with Administrator Peter Babaian and explained the reason for the visit.

The investigation consisted of: LPA reviewed the allegations with Administrator Peter Babaian. LPA requested and obtained copies of Register of Facility Clients/Residents (LIC 9020), Personnel Report (LIC 500), Unusual Incident/Injury Report (LIC 624), and other pertinent documentation regarding this investigation. LPA conducted four (4) Staff (S1 – S4) and four (4) Resident (R1- R4) interviews and attempted interviews of Residents (R5 – R6).

See 9099-C for continuation…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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-20210614155032

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: 03/06/2023

NARRATIVE

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Allegation: “Lack of supervision resulting in resident causing injury to another resident in care.” It is alleged on or about 06/10/2021, R5 received an injury from R6 due to lack of supervision. Four (4) out of the four (4) staff interviewed confirm R5 did receive an injury from R6. Four (4) out of the four (4) residents interviewed deny this allegation. LPA reviewed Unusual Incident/Injury Report (LIC 624) dated 06/10/2021 which documented the alleged injury to R5 by R6. LPA was able to verify local law enforcement was called on 06/10/2021 and R6 did not return to facility after 06/10/2021. LPA was unable to interview R5 and R6.

Allegation: “Resident has access to a hazardous item.” It is alleged on or about 06/10/2021, R6 had access to a hazardous item that caused injury to R5. Four (4) out of four (4) staff deny this allegation however, staff did acknowledge that residents in care do smoke cigarettes and require a lighter to light their cigarettes. S2 denied facility staff had prior knowledge that R6 would use or could use a lighter in a hazardous way on or around 06/10/2021. LPA could not locate any pertinent documentation that suggested R6 could not safely possess lighter while in care.

Allegation: “Staff did not safeguard resident's personal belongings.” It is alleged on or about 06/10/2021, R6 stole items from R5’s room. Four (4) out of the four (4) staff interviewed denied this allegation. Four (4) out of the four (4) residents interviewed denied this allegation. LPA could not locate any pertinent documentation to support this allegation.

Allegation: “Resident does not have access to the bathroom.” It is alleged on or about 06/10/2021, R5 was unable to access restroom due to R6 locking door and prohibiting access to R5. Two (2) out of the four (4) staff interviewed denied this allegation. S1 acknowledged R6 and R5 had a “Jack and Jill Bathroom” and R6 did lock the bathroom door so R5 would not walk in while R6 was occupying the restroom. According to S4, staff reminded R6 to unlock connecting bathroom door so R5 may gain access. Four (4) out of the four (4) residents interviewed deny this allegation.

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 held, and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

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