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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:27:26 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, 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
06/29/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210629083147
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: 53DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Assistant Administrator and Facility Administrator)TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Residents are not notified to participate in their appraisal needs and services plan.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Elizabeth Irra and Nune Margaryan conducted the initial 10-day complaint visit to investigate the above allegation. LPAs met with the Assistant Administrator and discussed the purpose of today's visit. The Facility Administrator arrived at approcximately 10:20 A.M. and assisted with this visit.

During today's visit, LPAs interviewed the Assistant Administrator (S-1), Facility Administrator (S-2), Licensed Vocational Nurse (S-3), Activities Director (S-4) and Housekeeper (S-5). LPAs also interviewed Resident #1 (R-1) through Resident #5 (R-5) and reviewed Residents files.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 3
Control Number 28-AS-20210629083147
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: 07/07/2021
NARRATIVE
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Allegation: Residents are not notified to participate in their appraisal needs and services plan.
During today's visit, LPAs interviewed the Assistant Administrator (S-1), Facility Administrator (S-2), Licensed Vocational Nurse (S-3), Activities Director (S-4) and Housekeeper (S-5). LPAs also interviewed Resident #1 (R-1) to Resident #5 (R-5) and reviewed Residents files. Staff interviews revealed that appraisal needs and services plans are developed by staff reporting directly to the Facility Administrator and/or the Assistant Administrator of what each Residents needs are. Staff interviews revealed that appraisal needs and services plans are not developed with the Residents being present. Staff interviews revealed that appraisal needs and services plans are developed and provided to the Residents by the Facility Administrator and/or Assistant Administrator after the development of the appraisal needs and services plan for review and signature. Resident interviews revealed that they were not aware nor have they participated in a appraisal needs and services plan meeting. Staff and Resident interviews corroborate this allegation.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiency as per California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.

An exit Interview was conducted with the Administrator, a copy of this report and Appeal Rights were provided

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210629083147
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: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2021
Section Cited
CCR
87463(c)
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Reappraisals: The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency,if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs
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Facility Administrator to ensure that Residents are participating in the development of any reappraisals including appraisal needs and services plan.

Facility Administrator to submit a written statement as to how Residents will be participating in the development of any
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first, as specified in Section 87467, Resident Participation in Decision Making.

This standard is not met as evidence by: Please refer to page (2) of the LIC 9099 report for details.
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reappraisals including appraisal needs and services plan by POC due date of 07/14/2021.
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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: Tony VasalloTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3