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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 07/09/2020
Date Signed: 07/09/2020 04:02:29 PM



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
03/30/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200330133808
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: 58DATE:
07/09/2020
UNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Peter BabaianTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility does not have a proper fire escape plan in place
Facility does not conduct fire drills
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted this visit in order to deliver investigation findings. As part of this investigation, LPA interviewed residents, staff, and the administrator. In addition, LPA reviewed the facility’s emergency disaster plan, physical plant sketch, and fire inspection paperwork.
Allegation #1, that “Facility does not have a proper fire escape plan in place,” has been substantiated based on the interviews conducted and records reviewed. Administrator confirmed on 4/30/20 and 6/18/20 that one of the facility’s exit gates has been locked as a COVID-19 procedure. On 4/7/20 Administrator provided a copy of the physical plant sketch showing which gate is locked.
Allegation #2, that “Facility does not conduct fire drills,” has been substantiated based on the interviews and records reviewed. On 4/1/20 Administrator stated that fire drills are conducted by an outside company which also tests the facility’s sprinkler system. He did not know the date of the last fire drill conducted but agreed to send a copy of the last report. Report received by LPA on 4/7/20 is dated 12/12/18 and does not reference a fire drill.
Report reviewed, signed, and delivered. Exit interview conducted, deficiencies cited on LIC9099D page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020
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 2
Control Number 31-AS-20200330133808
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: 07/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2020
Section Cited
CCR
87705(I)(2)
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87705(l)(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
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Administrator will ensure and confirm in writing that all perimeter fence and building exits are not locked.
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Based on administrator interview, the facility did not obtain a fire clearance to lock perimeter fences before doing so, which poses a potential risk to residents in care.
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Type B
07/16/2020
Section Cited
HSC
1569.695(c)
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1569.695(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents
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Administrator will provide proof of fire drills being conducted.
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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: Cassandra HarrisTELEPHONE: (818) 5964342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020
LIC9099 (FAS) - (06/04)
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