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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609485
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:32:10 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
10/27/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20221027090041
FACILITY NAME:AAA ROYAL SENIOR LIVING FACILITYFACILITY NUMBER:
197609485
ADMINISTRATOR:SHCHERBA,VIACHESLAVFACILITY TYPE:
740
ADDRESS:6214 BECKFORD AVETELEPHONE:
(818) 609-0117
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 2DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Slava ShcherbaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide assistance with resident's health needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 10:00 a.m. on 11/01/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Administrator and disclosed the reason for the visit.
LPA interviewed staff and Administrator on 10/27/2022 from 11:15 a.m. to 1:15 p.m. LPA interviewed medical staff on 10/31/2022 at 1:30 p.m. LPA conducted a records review on 11/1/2022 at 10:15 a.m.
Regarding the allegation above, it was alleged the facility did provide adequate care to Resident #1 (R1). R1 has mobility issues and range of motion exercises were recommended to prevent blood clots. From interviews, facility staff encouraged R1 to perform their exercises, but R1 often refused due to pain. Staff put pillows under R1’s legs when they were in bed, though R1 would kick the pillows off. Concerns were also raised about putting residents to bed too early. From interviews, staff reported they allow residents to go to bed whenever they please. Staff #1 (S1) reported that R1 once told them, “I have the right to be in bed”, so S1 respected R1’s personal rights. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Exit interview conducted. Copy of report and appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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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