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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:11:52 PM



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
11/23/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20211123155806
FACILITY NAME:ROYALTY ASSISTED LIVING IIFACILITY NUMBER:
197609666
ADMINISTRATOR:AVETIAN, LIDUSHFACILITY TYPE:
740
ADDRESS:17326 LOS ALIMOS STTELEPHONE:
(818) 436-9088
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estela AvetyanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident's medications are not properly stored.
Cleaning supplies are not properly stored.
Expired food stored in refrigerator.
Residents do not have access to the kitchen or food.
Facility staff does not conduct COVID-19 checks for visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegations. LPA was greeted by facility staff and the LPA explained the reason for the visit.

Allegation 1. Resident's medications are not properly stored.
At about 10:10 am, the LPA began touring the home. Upon touring the dining room, LPA did observe that three of the residents medication boxes were not locked away and were resting on the dining room table and accessible to the residents. The staff immediately removed the medications and stored them in a locked office room.

Based on LPA and staff observation, this allegation is deemed substantiated.

Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 6
Control Number 31-AS-20211123155806
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: ROYALTY ASSISTED LIVING II
FACILITY NUMBER: 197609666
VISIT DATE: 12/01/2021
NARRATIVE
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Allegation 2. Cleaning supplies are not properly stored.
While touring the kitchen area at about 10:20 am, LPA observed with staff, a can of disinfecting spray on a cabinet shelf accessible to residents. As the LPA continued the tour, LPA observed that the garage door was also open and accessible through the kitchen. Once in the garage, the LPA also observed additional cleaning chemicals that were not locked up and were accessible to residents in care.
Based on LPA and staff observation, this allegation is deemed substantiated.

Allegation 3. Expired food stored in refrigerator.
The LPA toured the kitchen at about 10:20 am and was able to inspect the refrigerator. Inside the refrigerator, LPA observed that there was an open pitcher of milk with chunks in it. At about 11:20 am, the facility director arrived and stated that the milk was made by another staff and should have been thrown out. The facility director also stated that the milk was powdered milk and was used for cooking only. The facility director did state that last week when the ombudsman was at the facility there were some questionable items in the refrigerator but they have all now been removed and that they are working on cleaning up the home. During todays visit, all other food observed was not expired except for the questionable milk in a pitcher.
Based on LPA and staff observation as well as the facility directors admission of questionable items being removed, this allegation is deemed substantiated.

Allegation 4. Residents do not have access to the kitchen or food.
LPA was able to interview staff and residents regarding this allegation. At 10:45 AM, LPA began interviewing residents. LPA was able to interview 3 out of the four residents at the home. All residents interviewed confirmed that the door to the kitchen is locked after dinner and residents do not have access to the kitchen. At 11:30 AM, the LPA interviewed the facility director and she confirmed that the kitchen is locked at night because she had a fear the residents might turn on the stove.
Based on information received from the facility director and interviews with residents, this allegation is deemed substantiated.



SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20211123155806
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: ROYALTY ASSISTED LIVING II
FACILITY NUMBER: 197609666
VISIT DATE: 12/01/2021
NARRATIVE
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Allegation 5. Facility staff does not conduct COVID-19 checks for visitors.
LPA arrived to the facility at about 10:00 AM and was allowed entry into the home. The facility staff did not take the LPA's temperature or ask any of the COVID-19 related questions upon arrival. Facility staff stated that she had not worked in a facility since before COVID-19 and was unaware of the protocols.

Based on staff confirmation and LPA observation, this allegation is deemed substantiated.


Exit interview conducted, deficiencies cited and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/23/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20211123155806

FACILITY NAME:ROYALTY ASSISTED LIVING IIFACILITY NUMBER:
197609666
ADMINISTRATOR:AVETIAN, LIDUSHFACILITY TYPE:
740
ADDRESS:17326 LOS ALIMOS STTELEPHONE:
(818) 436-9088
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estela AvetyanTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Food served is not of the quality to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegations. LPA was greeted by facility staff and the LPA explained the reason for the visit.

LPA was able to interview three out of the four residents residing at the home at about 10:45 AM. All residents interviewed stated that the food was very good and of nutritional value. None of the residents interviewed stated that they were ever served old or poor quality food. Facility staff and the facility administrator also confirmed that the residents have never been given expired or poor quality food.

Based on information received from residents and staff, this allegation is deemed unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20211123155806
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: ROYALTY ASSISTED LIVING II
FACILITY NUMBER: 197609666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2021
Section Cited
CCR
87465(h)(2)
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87465(h)(2) The following requirements shall apply to medications which are centrally stored. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The administrator agrees to hold an inservice regarding this regulation and submit the sign in sheet and training documents to the LPA by the POC date.
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This requirement is not met as evidenced by:Based on LPA and staff observation the administrator did not ensure the medication was inaccessible to residents in care, which poses an immidiate risk to the health and safety of residents in care.
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Type A
12/02/2021
Section Cited
CCR
87705(f)(2)
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87705(f)(2) Care of Persons with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The administrator agrees to hold an inservice regarding this regulation and submit the sign in sheet and training documents to the LPA by the POC date. Admin also agrees to add a lock to the garage door to restrict access to the chemicals.
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This requirement is not met as evidenced by:Based on LPA and staff observation the administrator did not ensure the cleaning chemicals were inaccessible to residents in care, which poses an immidiate risk to the health and safety of 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20211123155806
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: ROYALTY ASSISTED LIVING II
FACILITY NUMBER: 197609666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
CCR
87555b(8)
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All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on the facility directors confirmation, the administrator
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The administrator agrees to hold an inservice regarding this regulation and submit the sign in sheet and training documents to the LPA by the POC date.
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did not ensure that all expired food was removed from the refrigerator, which poses a risk to the residents in care.
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Type B
12/02/2021
Section Cited
CCR
87468(a)(2)
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87468(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews with staff and residents as well as LPA observation
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Administrator agrees to remove the lock from the kitchen door and to hold an inservice regrading this regulation and submit a sign in sheet and training materials as POC.
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The administrator denied access to the kitchen and did not practice the correct COVID -19 protocols as outlined in the mitigation plan, which poses a risk to the 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6