197608401-7-15-2021-28-AS-RORN-C5LVBA-20210805161710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 07/15/2021
Date Signed: 07/15/2021 10:44:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210707161111

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:	07/15/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Peter Babian; Administrator		TIME COMPLETED:	10:59 AM

ALLEGATION(S):

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Facility is not conducting fire drills.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Alise Nazarian and explained the reason for the visit. Administrator Peter Babian arrived shortly thereafter.

The investigation consisted of the following: LPA toured the facility and obtained Staff & Resident Rosters. LPA reviewed the LPA also interviewed the Administrator and Staff #1 - Staff #2.

The investigation revealed the following: in regards to the allegation "facility is not conducting fire drills", it is alleged that since the facility was last cited for this same allegation back in 2020, the facility has only conducted 1 fire drill. Per interview with Administrator, the last drill was conducted on 04/23/21 in the afternoon shift. However, Administrator was unable to provide documentation of said drill.

(CONTINUED ON 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

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-20210707161111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 07/15/2021

NARRATIVE

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Interviews conducted with S1 & S2 revealed that they do not recall the last time the facility conducted a drill. Therefore there was sufficient evidence to corroborate with this allegation.

Based on LPA's observations and interviews which were conducted 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 3.2 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report was provided to Administrator along with appeal rights.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210707161111

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/29/2021 Section Cited HSC 1569.695(c)	1 2 3 4 5 6 7	Emergency Plans (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... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.	1 2 3 4 5 6 7	Administrator to ensure drills are being conducted quarterly for each shift and documented with all required information. Administrator to conduct a drill for each shift by POC due date and submit documentation of said drills.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview with Administrator, last drill was conducted on 04/23/21. However there was no documentation available of said drill.This poses a potential Health, Safety, and/or Personal Rights risk to the residents 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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC9099 (FAS) - (06/04)

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