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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608401
Report Date: 06/22/2021
Date Signed: 06/22/2021 03:03:40 PM



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
06/14/2021 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210614094541
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: 52DATE:
06/22/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Peter Babian; AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility did not post Provider Information Notice (PIN) in a prominent place were residents can easily access it.
Facility in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) David Sicairos and Luis Mora conducted an unannounced complaint visit regarding the above allegations. LPAs met with Administrator Peter Babian and explained the reason for the visit.

The investigation consisted of the following: during today's visit LPAs obtained Resident & Staff Rosters. LPAs also toured the facility with Ms. Marta Marcheque which included all the common areas and a random sample of resident bedrooms. LPA also interviewed Staff #1 - Staff #5 and Resident #1 (R1) - Resident # 7 (R7).

The investigation revealed the following: in regards to the allegation "facility did not post Provider Information Notice (PIN) in a prominent place were residents can easily access it", it is alleged that the facility does not have the Covid-19 Provider Information Notice (PIN) posted anywhere in the facility easily accessible to residents. (PIN 21-17.2-ASC). Upon tour of the facility, LPAs did not observe any postings related to recent PIN's.

(CONTINUED ON 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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 6
Control Number 28-AS-20210614094541
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: 06/22/2021
NARRATIVE
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LPAs provided copy of PIN to Administrator and instructed Administrator to post in a prominent place easily accessible to residents. LPAs also instructed Administrator to update the PIN's as necessary.

In regards to the allegation "facility is in disrepair", it is alleged that some of the hand rails throughout the facility are loose and the main building restrooms do not have grab bars to use. It is also alleged that the majority of the toilets in the main building and the cottages are needing to be replaced or fixed properly because they clog and overflow daily. During physical plant tour of facility, LPAs observed the handrail coming in on the entry side of 1515 Glenn Ave side is loose and not securely attached. LPAs also observed that the two toilets located in the main building bathrooms do not have grab bars in close proximity. Interviews conducted with staff members revealed that bathrooms do not clog daily, however whenever a toilet is clogged they will assist residents with unclogging it or contact a plumber if necessary. Interviews conducted with R2 - R7 revealed that they have no issues with their bathrooms clogging.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

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


SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
06/14/2021 and conducted by Evaluator David Sicairos
COMPLAINT CONTROL NUMBER: 28-AS-20210614094541

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: 52DATE:
06/22/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Peter Babian; AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff don’t treat the resident’s with dignity and respect.
Staff not cleaning facility.
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
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9
10
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12
13
Licensing Program Analysts (LPA) David Sicairos and Luis Mora conducted an unannounced complaint visit regarding the above allegations. LPA met with Administrator Peter Babian and explained the reason for the visit.

The investigation consisted of the following: during today's visit LPA obtained Resident & Staff Rosters. LPA also toured the facility with Ms. Marta Marcheque which included all the common areas and a random sample of resident bedrooms. LPA also interviewed Staff #1 - Staff #5 and Resident #1 (R1) - Resident # 7 (R7).

The investigation revealed the following: in regards to the allegation "staff do not treat residents with dignity and respect", it is alleged that on 06/10/21 staff members got mad at R1 after he asked staff to clean the restroom after the toilet had overflowed. Interviews conducted with staff members revealed that they treat all residents with respect. Staff members indicated they do not get mad at residents when they are asked to assist them. Interviews conducted with R2 - R7 all indicated that staff members treat them with dignity and respect. Therefore there was insufficient evidence to corroborate with this allegation. (CONTINUED ON 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20210614094541
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: 06/22/2021
NARRATIVE
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In regards to the allegation "staff not cleaning facility", it is alleged that staff rarely clean the restrooms in the main facility and in the cottages. During today's tour of the facility, LPAs observed various housekeepers cleaning resident bedrooms and bathrooms. Interviews conducted with staff members revealed that staff clean resident bedrooms and bathrooms at least once a day, or as needed. Interviews conducted with R2 - R7 all indicated that they are happy with the cleaning that is done by staff. R2 - R7 indicated that facility staff clean their bedroom and bathrooms at least once a day. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210614094541
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: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited
CCR
87468.1(a)(10)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(10)To be informed of the licensee’s policy concerning visits and other communications with residents, according to Health and Safety Code section 1569.313.
This requirement is not met as evidenced by:
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Administrator to ensure all Provider Information Notices (PIN's) are posted, updated, and readily available for residents at all times.



*CLEARED DURING VISIT*
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Based on physical plant tour of the facility, LPA did not observe Statewide Waiver related to coronavirus disease 2019 (covid-19)(PIN 21-17.2-ASC) not posted anywhere in the facility. This poses a potential, health,safety, and or personal rights risk to the residents in care.
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Type B
06/29/2021
Section Cited
CCR
87303(e)(4)
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(e) Water supplies and plumbing fixtures shall be maintained as follows:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.



This requirement is not met as evidenced by:
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Administrator to ensure grab bars are maintained for each toilet, bathtub, and shower used by residents. Administrator to submit pictures once grab bars have been installed.
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During physical plant tour of the facility, LPA oberved the bathrooms located in the main building and the bathroom next to room #1 do not have grab bars next to the toilets. This poses a potential health, safety, and or/personal rights risk to the 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20210614094541
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: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2021
Section Cited
CCR
87303(a)
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(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:
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Administrator to ensure facility is in good repairs at all times. Administrator to repair loose handrail and submit pictures of repairs by POC due date.
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Based on tour of physical plant, LPAs observed the handrail coming in on the entry side of 1515 Glenn Ave is loose and unstable. This poses a potential health, safety, and/or personal rights risk to the 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6