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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:06:51 PM

Substantiated


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
05/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220510135636
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:
10/12/2023
UNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Peter Babaian, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff failed to provide appropriate care and supervision to resident after the fall.
Staff did not provide medical assistance to resident in a timely manner.
Insufficient staff to meet the needs of the resident(s).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on th above allegations that were investigated by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia. The purpose of the visit was explained to Administrator Peter Babaian.

The investigation consisted of: On 5/12/2022, LPAs Galarza and Yating Yang conducted a 24-hour health and safety check that included a physical plant tour of the facility, and review of resident (R1's) file. The following documents were obtained: Identification and Emergency Information, Preplacement Appraisal, Resident Appraisals, Physician Reports, Psychiatric Evaluation/Notes, Medication Administration Record (MAR), Admission Agreement, Assisted Living Waiver/Individual Service Plan, incident reports [5/5/2022 & 10/18/2021], notes, resident roster, LIC 500 Personnel Report, and Death Report. A police report was not obtained during the initial visit. Investigations Branch obtained Glendale Fire department, Police records, County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report and Registrar- Certificate of Death. A nurse consult was obtained.
****Narrative continues next page.*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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 7
Control Number 28-AS-20220510135636
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: 10/12/2023
NARRATIVE
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Allegation: Staff failed to provide appropriate care and supervision to resident after the fall. It is alleged that on 5/5/2022, resident (R1) sustained 2 falls. The 1st fall occurred at approximately 7:30 PM while being provided incontinence care by caregiver (S1) in the facility common bathroom. The 2nd fall was unwitnessed and occurred in the resident's room at approximately 8:00 PM - 8:30 PM. While staff (S1) was changing R1’s diaper in the common bathroom the resident fell to the ground. The resident was unable to get up on their own or with S1’s help due to their size. Caregiver/Staff (S1) used the Hoyer Lift to pick the resident up from the floor, and then proceeded to walk the resident back to their room. Facility staff failed to use proper equipment and follow equipment use guidelines when assisting R1 with incontinence care that resulted in the first fall in the bathroom. Staff placed R1 in the bed and returned to check on the resident at approximately 8:00 PM – 8:30 PM. Staff (S1) found the resident face down on the ground beside the bed. Staff (S1) stated that they decided to place a pillow under the head, so the resident did not get hurt, since R1 was likely to fall again. Staff (S1) stated the resident only replied “okay". Based on interviews with staff on duty, staff 9S1) and CNA/staff (S2) did not provide appropriate care and supervision after both falls. Review of evidence indicates that staff (S1) placed resident in a harmful situation by placing a pillow under the head (partially covering the face) and left the resident on the floor. Emergency personnel observed the resident's bed did not have any bed rails. Proper safety measures were not in place.

Allegation: Staff did not provide medical assistance to resident in a timely manner. It is alleged that facility caregiver (S1) and Certified Nurse Assistant (CNA)/Staff (S2) failed to provide timely medical attention by not rendering or initiating CPR when resident (R1) was not responsive. The facility failed to seek timely medical attention when R1 fell the 2nd time and was found on the floor. Emergency Medical Services (EMS) were not called almost two (2) hours after resident (R1's) 2nd fall, instead staff (S1) placed a pillow under the resident's head. Based on the photo, the resident was left on the floor in compromised position that appears to show R1 in prone position with left arm underneath body and right arm extended out in downward position. Caregiver staff (S1) reported both falls to CNA on duty. The 1st fall occurred at approximately 7:30 PM. The 2nd fall occurred at approximately 8:00 PM – 8:30 PM. At approximately, 9:30 PM, caregiver returned to the room to check on the resident because 2 other residents were heard screaming from R1's room. The resident was still laying on the ground with head on the pillow. Staff (S1) allegedly placed their index finger under the resident’s nose to see if any air was coming out from the nose. Staff (S1) stated the they felt air and left without providing further aid. According to staff interviews, staff (S1) reported the falls to Certified Nurse Assistant (CNA)/staff (S2). Sometime between 9:00 PM - 9:30 both staff went to check the resident. CNA stated that they stood by the door while staff (S1) checked on the resident and stated that staff (S1) reported the resident was okay. At 10:11 PM staff called EMS and reported to dispatcher that the resident was conscious. At 10:14 PM, EMS personnel arrived at the facility and found the resident "Dead on Arrival". Time of death was 10:17 PM. Paramedics determined the resident had been deceased longer six minutes.
***Narrative continues next page.****
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20220510135636
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: 10/12/2023
NARRATIVE
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Allegation: Insufficient staff to meet the needs of the resident(s). It is alleged that the facility did not have staff of adequate number and skill to provide care to the residents. When Emergency Medical Services (EMS) arrived staff delayed in allowing emergency responders crew into the facility. In addition, it is alleged that staff did not provide 911 emergency response dispatchers accurate information pertaining to resident's condition. Staff interviews revealed that during the afternoon shift staff (S1) is usually assigned to the front desk and when residents require immediate assistance it become very difficult to assist the residents. The findings indicate that on Saturdays and Sundays staff (S1) is the only person working from 2:00 PM - 10:00 PM; which includes providing the residents with meals, passing out medications, offering them snacks, and changing diapers for all the residents in need. In addition, the graveyard shift (10:00 PM - 6:00 AM sometimes has only one (1) staff working, and two hourly checks are not always performed. Staff interviewed acknowledged that due to staffing shortages, neglect and lack of supervision are likely. On May 5, 2022, both staff on duty (S1) and (S2) failed to provide medical assistance (CPR) or conduct a body assessment on resident (R1). On the resident (R1's) Appraisal/Needs and Services Plan dated 12/3/2020, it states the resident is at risk for falling, needs assistance with daily activities, and daily monitoring/observation will be performed.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22 and Health and Safety Code.

***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM.

The issuance of a civil penalty is being considered based on Health & Safety Code HSC §1569.49(e) – (f), if the department determines the serious bodily injury was due to neglect.


Exit interview was conducted with Peter Babaian. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20220510135636
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care (a) ...The plan...shall provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical care... appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Administrator shall submit in writing how this deficiency will be addressed, understanding of regulation, and facility procedures regarding timely medical care.

1.Submit plan by tomorrow.
2. Submit proof of staff training by Oct. 19,2023.
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Based on documents reviewed and interviews conducted, facility staff failed to call Emergency Medical Services (EMS) personnel in a timely manner. Staff called 911 EMS approximately 2 hours after 2nd fall was discovered. This poses an immediate health and safety risk to residents in care.
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Type A
10/13/2023
Section Cited
CCR
87411(a)
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Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by evidence of:
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Administrator agreed to (1.) submit a plan of correction that addresses staff scheduling and supervision of residents. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of staff training i.e., needs and services of residents, resident care, and supervision.
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Based on document review and interviews conducted, on May 5, 2022 facility staff failed to meet the needs of resident (R1) after 2 fall incidents; by not conducting body assessments or providing adequate supervision subsequent to falls. This posed an immediate safety risk to this resident 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20220510135636
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
87466
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Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator agrees to conduct training with all staff regarding observation of residents and changes in condition. When changes in condition are observed residents shall be assessed and records and Appraisals Needs and Services plan shall be updated.
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This requirement was not met evidenced by: Based on record review on May 5, 2022, R1 had 2 falls, (one in incontinence care room & the other in their room); staff did not provide appropriate care and supervision after both falls. This poses a potential health and safety risk to residents 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/10/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220510135636

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:
10/12/2023
UNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Peter Babaian, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
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5
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Questionable Death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on th above allegations that were investigated by DSS/CCLD Investigations Branch (IB) Investigator Laura Garcia. The purpose of the visit was explained to Administrator Peter Babaian.

The investigation consisted of: On 5/12/2022, LPAs Galarza and Yating Yang conducted a 24-hour health and safety check that included a physical plant tour of the facility, and review of resident (R1's) file. The following documents were obtained: Identification and Emergency Information, Preplacement Appraisal, Resident Appraisals, Physician Reports, Psychiatric Evaluation/Notes, Medication Administration Record (MAR), Admission Agreement, Assisted Living Waiver/Individual Service Plan, incident reports [5/5/2022 & 10/18/2021], notes, resident roster, LIC 500 Personnel Report, and Death Report. A police report was not obtained during the initial visit. Investigations Branch obtained Glendale Fire department, Police records, County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report and Registrar- Certificate of Death. A nurse consult was obtained.
****Narrative continues next page.*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20220510135636
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: 10/12/2023
NARRATIVE
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Allegation: Questionable Death. It is alleged that resident (R1) died at the facility due to neglect of care. On 5/5/2022, at approximately 8:00 PM - 8:30 PM caregiver staff (S1) found the resident laying in a prone position with face down but did not pick-up the resident, only placed a pillow under its head, and left the resident on the floor. Night shift staff placed a 911 emergency call until 10:11 pm. The decedent was found dead by emergency responders. Resident (R1) had bruising on their lower back that led further under the diaper, had a fresh cut on back, and had a visible dislocated left shoulder. A picture was taken, and appears to show R1 in prone position with his left arm underneath and right arm extended out in downward position. Left knee bent with left foot darker color extending pass their ankle. Based on County of Los Angeles Department of Medical Examiner- Coroner Autopsy Report (5/8/2022) and Registrar- Certificate of Death records the cause of death is listed as "Natural". Other conditions contributing but not related to immediate cause of death listed Diabetes Mellitus and lymphoma. There is insufficient evidence to substantiate death as autopsy report ascribe cause of death to Arteriosclerotic Cardiovascular Disease and manner of death as natural.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted with Peter Babaian. A copy of the report was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7