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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 02/02/2024
Date Signed: 02/12/2024 03:05:47 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
05/12/2021 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20210512113511
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:0CENSUS: 0DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Estela Avetyan, Co-AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff served cleaning solution to resident in care during meal service.
Food services are inadequate.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Angela Panushkina and Perchui Milena Khurshudyan met with the Co-Administrator, Estela Avetyan, at Regional Office (RO) conference room and explained the reason for the visit.

On 05/12/2021, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations, “Staff served cleaning solution to resident in care during meal service” and "Food services are inadequate."

On 05/24/2021, LPA Martina Berry initiated the complaint. During the inital visit, LPA toured the facility and conducted an interview with the facility Director and two (2) out of four (4) residents, who were able to communicate. LPA also obtain copies of recent incident reports. In addition, on 05/25/21, LPA conducted an interview with two (2) credible witnesses regarding the above allegations.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 4
Control Number 31-AS-20210512113511
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: 02/02/2024
NARRATIVE
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Allegation: Staff served cleaning solution to resident in care during meal service.

To investigate this allegation, LPA Berry conducted an interview with Resident #1 (R1) and Resident #2 (R2) and both informed the LPA that on 05/06/21 facility Staff #1 (S1) served a house cleaner, instead of an "orange juice" to R1, by mistake. As R1 took the first sip, R1 realized that something was not right with the juice and asked R2 to smell the drink to see if they noticed anything strange. Although, R1 did not finish the drink, R2 informed LPA that R1 had stomach problems for several days. Interview with the Administrator confirmed that S1's action was an unacceptable accident, and the facility was going to replace S1, immediately. In addition, LPA’s interview with the credible witness (CW) revealed that he/she conducted a visit on 05/17/21 to investigate the incident that was reported to his/her agency. CW informed LPA Berry that during his/her investigation with S1, S1 apologized and acknowledged the mistake.

Allegation: Food services are inadequate.

To investigate this allegation, LPA Berry conducted an interview with R1 and R2 and both informed the LPA on 07/12/2021 that the facility does not provide fresh food and the food is mostly canned with too much salt. Moreover, interview with both residents confirmed that the facility provides poor quality food to the residents.

Based on the information gathered, there is sufficient evidence to conclude that the above two (2) allegations are Substantiated.


Although, the facility was closed effective 3/10/2023, during todays visit, deficiencies will be cited on LIC9099-D.

Exit interview conducted. Appeal right explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210512113511
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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2024
Section Cited
CCR
87309(a)(d)
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Storage Space: (a) Disinfectants, cleaning solutions...shall be stored where inaccessible to clients. (c) The items specified in (a) above shall not be stored in food storage areas or in storage areas used by or for clients.
This requirement is not met as evidenced by:
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Facility is closed effective 03/10/2023

Dificiency cleare during today visit
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Based on observation, the licensee did not comply with the section cited above as cleaning solution was given to R1 instead of the orange juice which poses/posed an immediate health, safety or personal rights risk to persons 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: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20210512113511
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: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2024
Section Cited
CCR
87555(a)
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General Food Service Requirements. The total daily diet provided for the residents shall be selected, stored, prepared and served in a safe and healthful manner and shall be of the quality and in the quantity necessary to meet the needs of the residents.
This requirement is not met as evidenced by:
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Facility is closed effective 03/10/2023

Dificiency cleare during today visit
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Based on interviews, the licensee did not comply with the section cited above as two (2) residents informed LPA that the facility provides poor quality food to the residents. which poses/posed an immediate health, safety or personal rights risk to persons 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: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4