197609485-10-27-2022-31-AS-NMAN-CNDR5W-20230124114350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609485
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:19:46 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
10/07/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20221007110909

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: 3	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Slawa Scherba		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident was found unkempt while in care.

INVESTIGATION FINDINGS:

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At 10:45 a.m. on 10/27/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit.
LPA conducted an initial visit on 10/13/2022 and interviewed facility Staff #1 (S1) and Staff #2 (S2) from 10:55 a.m. to 11:40 a.m. LPA interviewed Visitor #1 (V1) on 10/14/2022 at 4:30 p.m., Visitor #2 (V2) on 10/25/2022 at 3:33 p.m., and the hospice agency on 10/26/2022 at 11:00 a.m. LPA conducted further interviews with S1 and S2 on 10/27/2022 from 11:15 a.m to 12:00 p.m. LPA conducted record reviews on 10/13/2022 at 11:40 a.m. and on 10/20/2022 at 1:00 p.m.

Regarding the allegation above, it was alleged Resident #1 (R1) arrived at the hospital unkempt and dirty. From record review, R1 required maximum assistance, required continuous bed care, and had no ability for self-care of toileting, bathing, and dressing needs. R1’s dysphagia required a G-tube for feeding. R1 was bedridden and had left arm weakness from a stroke. From interviews, V1 and V2 observed R1 wearing only a diaper, having no blankets, and having long, untrimmed nails and hair.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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-20221007110909

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: 10/27/2022

NARRATIVE

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The hospice agency reported they were responsible for R1’s medical care needs such as changing R1’s G-tube and dressing wounds. S1 and S2 reported cleaning R1’s mouth and face but did not provide haircuts or trim nails. The Administrator did not have a hospice care plan for R1’s care needs. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D.

Exit interview conducted. Copy of report and appeal rights issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20221007110909

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/25/2022 Section Cited CCR 87633(b)(4)	1 2 3 4 5 6 7	87633 Hospice Care of Terminally Ill Residents (b) A current... hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the area of licensee’s responsibility for implementing the plan. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct an in-service training on the section cited for all staff and Administrator and proivde proof by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 11/25/2022 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct an in-service training on the section cited for all staff and Administrator and proivde proof by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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