197608401-1-26-2024-31-AS-MVAO-D27S7S-20240206123802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 01/26/2024
Date Signed: 01/26/2024 09:32:04 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20240122122023

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: 53	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Peter Babaian, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, Perchui Milena Khurshudyan conducted an unannounced, joint visit with Investigator, Johnny Canto, at this facility to investigate the above allegation. The team met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Centrally Stored Medication and Distruction Record (CSMDR), Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:30am, the team conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:40am – 1:15pm, the team conducted an interview with the Administrator, Administrator Assistant, MedTech, two (2) staff, two (2) housekeepers, and five (5) residents out of six (6) residents.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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 6

Control Number 31-AS-20240122122023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 01/26/2024

NARRATIVE

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During the interviews, the team was able to visit four (4) random resident rooms and inspected/tested four bathroom sinks/faucets for the leaks. The team did not observe any faucets leaking. Interviews with five (5) out of six (6) residents revealed that they had no issues with the shower and or faucet leaks. However, in two (2) out of four (4) rooms, the team observed that the outlet wall plates were broken/missing. Administrator informed the team that the electrician was already contacted and the work will be completed today. Based on the inspection and observation, this allegation is Substantiated.

Deficiency cited on LIC9099-D.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20240122122023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/02/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator already contacted the electrician to replace/fix the outlet today. Proof of picture shall be submitted to LPA by POC date.
	8 9 10 11 12 13 14	Based on the observation, licensee failed to ensure that the outlets in room #6 and room #22 had a wall plates, wich poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20240122122023

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: 56	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Peter Babaian, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff does not provide PRN medication to residents in a timely manner
Staff refused to seek medical attention for resident
Staff does not keep the facility clean and sanitary
Staff does not safeguard resident's personal items
Staff is disrespectful to resident.

INVESTIGATION FINDINGS:

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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina, Perchui Milena Khurshudyan conducted an unannounced, joint visit with Investigator, Johnny Canto, at this facility to investigate the above allegation. The team met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Centrally Stored Medication and Distruction Record (CSMDR), Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:30am, the team conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 1:15pm, the team conducted an interview with the Administrator, Administrator Assistant, MedTech, two (2) staff, two (2) housekeepers, and five (5) out of six (6) residents. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20240122122023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 01/26/2024

NARRATIVE

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Allegation: Staff does not provide PRN medication to residents in a timely manner

It was alleged that staff does not provide PRN medications to residents in a timely manner. To investigate this allegation, the team conducted an interview with the Administrator and the MedTech and was informed that all PRN medications are provided to residents in a timely manner and the staff immediately initials the PRN log. In addition, interviews with four (4) out of six (6) residents revealed that they never had any problems taking their medications or waiting for their medications for a long period of time. Lastly, the team conducted an inspection of R1's prescribed and PRN medications and did not observe R1 being prescribed a PRN (Ativan) medication. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.

Allegation: Staff refused to seek medical attention for resident.

To investigate this allegation, the team conducted an interview with the Administrator and was informed that the facility staff always contacts 911 when an incident occurs with residents. Once the paramedics arrive and determine that it is not an emergency situation they may not take the resident to an Emergency Room (ER). In addition, the team was informed that the resident also has an option to refuse 911 services, upon paramedics arrival. Moreover, the team was informed that R1 calls 911 very frequently and most of the time the calls are done for a false emergency situation due to R1's medical and mental condition. Interview with two (2) staff members revealed that before their employment facility provided a training regarding the emergency situation and procedures. Both staff members also informed the team that each and every emergency situation is being handled, immediately. Interviews with four (4) residents revealed that the staff members are well trained and handle emergency situations on a professional level. Lastly, review of R1 Incident Reports confirmed that the facility always calls 911 when resident expresses behavior episodes and or upon residents' request. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.

Allegation: Staff does not keep the facility clean and sanitary

To investigate this allegation, the team visited five (5) resident random rooms and observed all rooms are clean and well taken care of. The team also conducted an interview with two (2) housekeepers and was informed
Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20240122122023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 01/26/2024

NARRATIVE

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that the facility resident rooms and common areas are being cleaned every day. Lastly, the team conducted interviews with five (5) residents and none of the residents expressed any issues/concerns regarding this allegation. Based on observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegations is Unsubstantiated at this time

Allegation: Staff does not safeguard resident's personal items.

It is alleged that R1's personal item has gone missing. During today's walk through, the team observed that the missing item that was initially reported missing was actually present at R1's room. In addition, interview with the Administrator revealed that at times residents may misplace their personal items and once it brought up to the management's attention the facility staff will relocate and return the missing item. Moreover, the team conducted interviews with five (5) residents and four (4) out of five (5) residents did not express any concerns regarding this allegation. Based on observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegations is Unsubstantiated at this time.

Allegation: Staff is disrespectful to resident.

It was alleged that facility staff members yell at the residents during the dinner time if they don't hurry finishing their meals on time (by 6:00pm). Interviews with the Administrator, two (2) staff members revealed that at times staff members might raise their voice to those residents that are hard of hearing. When they speak to those residents that are hard of hearing the raising of their voice is not meant to be in anger/disrespect, it is just so that the resident understands what the staff members are talking about. Moreover, interviews with four (4) out of six (6) residents confirmed that they are being treated very well by the facility staff members and were never treated disrespectfully by the staff. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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