197609666-5-6-2022-31-AS-NMAN-CPWSC6-20230314134501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:12:14 PM

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
05/28/2020 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20200528124305

FACILITY NAME:	ROYALTY ASSISTED LIVING II		FACILITY NUMBER:	197609666
ADMINISTRATOR:	AVETIAN, LIDUSH		FACILITY TYPE:	740
ADDRESS:	17326 LOS ALIMOS ST		TELEPHONE:	(818) 436-9088
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Estela Avetyan/Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident was found with multiple injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patrick Shanahan arrived at the facility in response to the above mentioned allegation. There was no one at the location when the LPA arrived and the facility Director was Called. The Director arrived shortly after.

On 6/03/2020, an initial telephone visit was conducted at this location. A request for the resident roster was requested and was received on 6/03/2020. The resident in question (R1) was not noted to be a resident and an interview conducted with the director on 6/3/2020 and an interview conducted on 5/6/2022 revealed that R1 never lived at this location. LPA attempted to interview 2 other residents who lived at the home during the time of this initial complaint. R2 was unable to speak and R3 did not recall R1 ever being at the home.
Based on interviews conducted with the facility Director and a review of the resident roster, indicating that R1 was not a resident, This allegation is deemed Unsubstantiated.
Exit interview conducted and report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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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