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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608636
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:34:15 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
02/22/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230222110103
FACILITY NAME:ROYAL TRINITY ENRICHMENT CENTERFACILITY NUMBER:
197608636
ADMINISTRATOR:BERNARD MOSES ISIKOFACILITY TYPE:
735
ADDRESS:13142 CROWLEY STREETTELEPHONE:
(747) 223-2115
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY:6CENSUS: 6DATE:
03/03/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kumbirai Zvaita, Designee TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not properly store medication
Facility has insufficient staffing for the clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with the facility Designee, Kumbirai Zvaita, and explained the reason for the visit.

During today’s visit, a staff member contacted the Administrator, Bernard Moses Isiko. Administrator was not able to come to the facility and designated staff to sign for the report.

Allegation: Staff did not properly store medication. To investigate this allegation, from 9:40am to 10:30am, LPA conducted interviews and reviewed documents pertaining to the allegation. The incident occurred on February 3, 2023 at 10:30 AM in the garage of Royal Trinity Enrichment Center when the behaviorist stepped away to ask the home staff for an assistance. During the time that C1 was left in the garage, he/she had an access to the medication that was stored in the refrigirator. During today’s visit, LPA confirmed and identified that the Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 3
Control Number 31-AS-20230222110103
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: ROYAL TRINITY ENRICHMENT CENTER
FACILITY NUMBER: 197608636
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited
CCR
80075(k)(1)
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80075 Health Related Services: (k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...

This requirement is not met as evidence by:
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Licensee/Administrator will submit CCL vendor trainig and staff signatures pertaining to Section 80075. Licensee/Administrator will inform LPA when the training will be conducted via email.
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Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to keep the PRN medication (for the staff) locked and inaccessible to clients, which poses an immediate health and safety risk to persons in care.
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Type A
03/03/2023
Section Cited
CCR
80028(b)(6)
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80028(b)The number of persons for whom the facility is licensed to provide care and supervision shall be...(6)Number of available staff to meet the care and supervision needs of the clients.
This requirement is not met as evidence by:
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Licensee/Administrator will submit a detailed plan as to what steps will be taken to ensure that their staffing ratios are met at all times by POC due date.
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Based on LPA observation and various interviews conducted which revealed that facility does not have enough staff necessary to meet the clients needs which poses an immediate health and safety and personal rights 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230222110103
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: ROYAL TRINITY ENRICHMENT CENTER
FACILITY NUMBER: 197608636
VISIT DATE: 03/03/2023
NARRATIVE
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facility did not properly store the medication (that belong to the staff member) in the garage and it was kept unlocked and accessible to clients in care. In addition, the Administrator also admitted the medication error. This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Facility has insufficient staffing for the clients

On February 13, 2023, a credible witness conducted an unannounced visit to Royal Trinity Enrichment Center. At the time of arrival at approximately 4:00pm, there were five (5) clients at the home with only one staff (S1), supervising the five (5) clients. According to the posted staffing schedule, three (3) staff were supposed to be on duty. During todays visit, LPA conducted an interview with the Administrator and S1 and both confirmed that on 02/13/23 the facility had only one (1) staff member supervising five (5) clients. Based on interviews conducted, the allegation is deemed Substantiated.

Deficiency cited on LIC 9099 D.

Appeal Rights explained. Exit Interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3