197609485-11-1-2022-31-AS-NMAN-CNDQZA-20230124113626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609485
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:34:49 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-20221027091753

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: 2	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Slava Shcherba		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility did not provide adequate supervision

INVESTIGATION FINDINGS:

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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 home health staff on 10/31/2022 at 1:30 p.m. LPA conducted record reviews on 10/27/2022 at 10:30 a.m. and on 11/1/2022 at 10:15 a.m.

Regarding the allegation above, it was alleged the facility did not provide adequate supervision to Resident #1 (R1) which led to a burn on their shoulder. The facility submitted an incident report on 10/21/2022 regarding the incident which took place on 10/13/2022. R1 fell at the facility and suffered a skin tear on their right shoulder while transferring from the sofa to their wheelchair. From interviews, home health nurses were aware of the injury and provided medical treatment beginning on 10/18/2022. R1 received home health services for the injury approximately twice per week. Facility staff noted that R1 had difficulty waiting for staff assistance.

Unsubstantiated

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: 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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Control Number 31-AS-20221027091753

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: 11/01/2022

NARRATIVE

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R1 tried to maintain independence and thus did not request staff assistance when transferring to and from their wheelchair. From record review, R1’s Physician Report showed they were able to follow instructions, able to communicate their needs, had no motor impairment, and no mental or cognitive impairment. Based on record review and 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 provided. Appeal rights discussed.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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