197609485-4-28-2022-31-AS-NGID-CECPXM-20220512114235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609485
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:00:19 AM

Unsubstantiated

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
08/13/2020 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20200813101735

FACILITY NAME:	AAA ROYAL SENIOR LIVING FACILITY		FACILITY NUMBER:	197609485
ADMINISTRATOR:	SHCHERBA,VIACHESLAV		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	VIACHESLAV SHCHERBA, ADMINISTRATOR		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Facility staff did not allow resident visitors

Facility staff interfered with and confiscated resident's phone

INVESTIGATION FINDINGS:

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On 4/28/22 Licensing Program Analyst met with Administrator to deliver the finding of the complaint allegations.
Entrance interview conducted.

On 08-19-2020 this department initiated the complaint virtually due to the situation surrounding the Corona Virus Disease(COVID-19). This day at 1:50 pm a virtual physical plant tour was conducted, interviews with staff, and interviews with residents who were able to communicate were conducted. Request for records were made, received and reviewed on 08-19-2020.

The investigation revealed that during this time there was a Governor’s Proclamation surrounding COVID-19 and the department announced statewide waiver for certain licensing requirement which included visitation. Visitation was limited to essential visitors. Visitation with others was conducted by phone calls, virtually, and or drive by. CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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 31-AS-20200813101735

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197609485
	VISIT DATE: 04/28/2022

NARRATIVE

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The complainants concern is that facility did not allow resident #1(R1) to have visitors in effort to attempt to isolate and coerce the resident to stay at the facility.

Interview reveal that the Administrator was not prohibiting R1 or other resident from having visitors in an effort to isolate and coerce the resident(s) to stay at the facility. The particular incident took plans

on June 30, 2020 when R1 received a visit from two individuals. The resident was informed of the visit. According to interviews R1 did not recognize the two individuals and did not want to move from the facility. Neither individuals had conservatorship or Power of Attorney (POA) in any capacity over the resident. The Administrator indicated that the police had to be called because the individuals who showed up were trying to get R1 to sign a large sum check to be used as a down payment on a condo in which R1 would stay after an upcoming surgery. The Administrator found that unusual and contacted the police. After having a conversation with police, the two individuals were told to give back R1 check book and leave the premises. Therefore, after review of the information received the allegation is unsubstantiated.

Allegation: Facility staff interfered with and confiscated resident's phone.

Interviews were conducted with facility Administrator and the resident in question R1 one on 08-19-2020. According to the Administrator the resident’s cell phone was never confiscated. It was stated that the resident left their phone at the facility while they were in the hospital for a COVID related issue end of July beginning of August 2020. The Administrator indicated that on an unspecified date the phone kept ringing therefore answered it to respond on behalf of the resident who was in the hospital. The Administrator indicated that at times when the resident is on a call the resident would ask for assistance from the Administrator with phone calls from the doctor and or family. The residents would hand over the phone and give permission to ask need questions. Interviews with resident in question R1 indicated that the telephone was never confiscated and at times will call the Administrator for help when communicating with others on the phone. Therefore, after review of the information received there is insufficient evidence to conclude that the facility staff interfered with and confiscated the resident’s phone. The allegation is unsubstantiated at this time.

Exit interview conducted. Appeal rights and copy of report given to Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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