197608401-3-22-2023-28-AS-NGID-CW9Q9G-20231003115819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:27:23 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
02/10/2023 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230210163900

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:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Peter Babaian		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident wandered away from the facility due to lack of supervision

INVESTIGATION FINDINGS:

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On 03/22/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). 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, interviews and deliver findings for this complaint.

The investigation consisted of the following: on 02/13/2023 LPA Agard initiated a complaint investigation. LPA toured the physical plant and requested records. The following records were requested: 1) staff roster, 2) resident roster, 3) needs and services plan for R1, 4) physician report for R1, 5) Identification and emergency contact information and 6) police report. All records were received at the time of visit.

Cont. on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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-20230210163900

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: 03/22/2023

NARRATIVE

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The investigation revealed the following: Regarding the allegation… Resident wandered away from the facility due to lack of supervision. It’s being alleged a resident walked out of the facility unsupervised and remains missing. LPA Agard interviewed 2 out of 16 staff in total. 2 out of 2 were able to confirm the allegation. S1 states, “R1 left and never came back. We called the police the same day. We’ve called the hospital. Every 2-3 days we call the police to get updates but still nothing. R1 didn’t say anything or sign out. They are independent in the community.” S2 states, “that day when staff checked, R1 wasn’t there. We checked everywhere. We waited a few hours to make sure because our residents go out. We called hospitals, the police department and so far, we haven’t heard anything. The police can’t even find them.

During interviews with residents, LPA interviewed 5 out of 54 residents in total. 2 out of 4 confirmed the allegation. R1 was unavailable for an interview. R2 states, “I only know that they said were going to “Alvarado near MacArthur Park.” R3 states, “I’m not sure, the last time they eloped was about a year ago. They found them in some place called Alvarado near a park. R4-5 were unable to speak on the allegation.

During a record, LPA reviewed R1’s physician report dated 01/01/2022 which indicates resident is unable to leave the facility unassisted. LPA reviewed R1’s resident appraisal dated 06/01/2022 which indicates residents need for special observation/ night supervision and help with moving about the facility. LPA reviewed R1’s needs and services plan dated 01/01/2022. Under the section functioning skills, it states: “R1 needs support with activities of daily living, is not able to go outside and needs assistance with medical and financial management.

Based on the interviews with staff, residents and a record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is (are) 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 Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230210163900

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: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/29/2023 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirements – General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3)	1 2 3 4 5 6 7	Administrator shall review the regulation 87411 and residents' Physician's Report. Administrator shall submit the list of residents who cannot leave the facility unassisted and the plan to ensure those residents do not elope by POC due date. Plan can be submitted via fax or email to LPA.
	8 9 10 11 12 13 14	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: observation, interviews conducted and record review. A resident that required supervision was able to elope from the facility unsupervised and remains missing. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14
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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 Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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