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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:24:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230123083331
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: 54DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Peter BabaianTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff inappropriately completed resident's Physician Report
Resident is not notified to participate in care plan
INVESTIGATION FINDINGS:
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On 01/25/2023 Licensing Program Analyst (LPA) Troy Agard conducted an initial complaint investigation at the above facility to address the following allegations. LPA Agard was met first by Alise Nazarian, Assistant Administrator, and then by Peter Babaian, Administrator. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint.

The investigation consisted of the following: LPA toured the physical plant. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA requested the following records: 1) staff roster, 2) resident rosters, 3) needs and services plan for R1, 4) physician report for R1. All records were received at the time of visit.

cont on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4
Control Number 28-AS-20230123083331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
VISIT DATE: 01/25/2023
NARRATIVE
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The investigation revealed the following: Regarding the allegation… Staff inappropriately completed resident's Physician Report. It’s being alleged the facility is completing sections of the physician report that should be completed by the resident or physician. LPA interviewed 5 out of 54 residents in total. 1 out of 5 confirmed the allegation. R2-5 all state not being aware of the allegation, their physician’s report or a combination of both. R2 states, “I don’t know what a physicians report is and have never seen one so I can’t say.” R4 states, “I’ve never seen that form but why would I need it. I don’t know about the allegation.” R1 states, “they don’t follow the direction of how to fill out the form. When I was given the form, it was not blank. They fill in a lot of things that were supposed to be left blank. I notice the licensee is S2, but it supposed to be the Limited Liability Company (LLC) and not a person.”

During interviews with staff, LPA Agard interviewed 3 out of 16 in total. 0 out of 3 were able to confirm the allegation. S1 states, “we usually give R1 a blank form to give to their doctor and bring it back completed.” S2 states, “physician reports we don’t touch. R1 takes it and brings it back.” R3 states, “I complete the top section like height, weight and blood pressure. The back pages are completed by the doctor.”


Regarding the allegation: Resident is not notified to participate in care plan. It’s being alleged the facility is not notifying residents about their needs and services plan meetings. 4 out of 5 confirmed the allegation. R2-4 were all unable to confirm they have participated in the collaboration of creating their needs and services plans. R2-4 were all unaware of what the needs and services plan was prior to LPA explaining it and what the plan entails. R1 states, “they haven’t been doing that over the years. They are supposed to do it yearly or if a significant change happened. They haven’t been coming to me and they haven’t been doing the interviews.”

During interviews with staff, 2 out of 3 confirm the allegation. “S1 states, R1 never asked to be a part of it.” R3 states, “I complete the LIC 625. It depends on the resident. Some are smart and alert about what I’m asking. Some of them don’t understand or don’t want to talk. It depends on the resident. S1 does the report for R1.”

During a record review, LPA Agard observed parts of a physician’s report dated January 2023, that was given to the resident for completion, to be inaccurate or some sections were completed by the facility that should
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230123083331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
VISIT DATE: 01/25/2023
NARRATIVE
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have been completed by the doctor. LPA observed no changes to these sections, but the facility has reported changes to resident’s overall health and ability to ambulate. Thus, making the pre-fill physicians report inaccurate. Based on interviews conducted, LPA observed and interviewed some residents that have the capability of participating in their needs and services plan be completely unaware of the document’s existence or purpose. Residents were not able to confirm having a needs and services meeting annually or as needed.

Based on the interviews with staff, residents and a record review, 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 LIC9099-D.

An exit interview was conducted, and a hard copy was provided with appeal rights.
See LIC 9009-D on the next page
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230123083331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
87468(e)
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Personal Rights At the request of the Department, and immediately if the request is made during an inspection, a licensee shall provide the Department with a confidential list of residents that includes the language(s) read by each resident, which is to be kept confidential to the extent permitted by law. This list shall be
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Facility will discontinue completing sections of the LIC 602 and obtain an updated copy of R1’s physician report. The report must be completed by R1’s Physician. Proof of correction must be sent to LPA via fax or email by POC due date.
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maintained in an accurate and current status at all times. This requirement was not met as evidence by: based on record review, sections of the LIC 602 was completed by the facility that should have been completed by the resident or physician. This poses a potential risk to clients in care
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Type B
02/23/2023
Section Cited
CCR
87467(a)(3)
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Resident Participation in Decision-making: The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant
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Facility will conduct a review of the needs and services plan with R1 collaboratively and any resident with the capability moving forward. Facility must submit an updated plan for R1 via fax or email by POC due date.

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changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement was not met as evidence by: Based on interviews conducted: Residents have not been participating in the needs and services plan assessments. This poses a potential risk to clients in care.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4