197609666-11-24-2021-31-AS-MVAO-D3YRPX-20240403131238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:35:55 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
11/19/2021 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211119095903

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: 4	DATE:	11/24/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Stella Avetyan - Director		TIME COMPLETED:	12:44 PM

ALLEGATION(S):

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Medications are accessible in the refrigerator.
Medication records are not up to date.
There is no medication log.

INVESTIGATION FINDINGS:

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At 9:30 a.m., Licensing Program Analyst (LPA) Melissa Ruiz made an unannounced visit to conduct a complaint investigation for the allegations mentioned above. Upon arrival, LPA was greeted by staff 1 (S1) and later met with Director Stella Avetyan.

Allegation #1 Medications are accessible in the refrigerator.

To investigate this allegation, LPA conducted a tour of the kitchen with S1 and at 9:53 a.m., LPA observed medications accessible in the refrigerator. Interviews conducted with S1 and Director revealed that they store some medications in the refrigerator as they must be kept refrigerated. Based on LPA observation and interviews conducted this allegation is substantiated at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

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 4

Control Number 31-AS-20211119095903

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: 11/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/29/2021 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Director has agreed to do the following: Secure the medications by end of day, today and document a Plan of Action to ensure that medication that requires refrigeration is kept inaccessible to residents. Submit by 11/29/21.
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee failed to ensure that items were inaccessible to residents with dementia, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 11/29/2021 Section Cited CCR 87705(h)(6)	1 2 3 4 5 6 7	87465 (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician.(C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Director stated they will continue to update centrally stored medication logs for all residents in care and conduct in-house training with staff regarding regulation 87705(h)(6). A written statement of the training and medication logs to be submitted by 11/29/21.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not ensure that a record of centrally stored prescription medications for each resident is maintained. This poses an immediate health and safety risk to residents 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 31-AS-20211119095903

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: 11/24/2021

NARRATIVE

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Allegation #2 Medication records are not up to date.
Allegation #3 There is no medication log.

To investigate the allegations above, LPA conducted document review from 10:30 a.m. to 11:00 a.m. LPA reviewed the Medication Administration Record (MAR) for three out of four residents, all of which appear to be missing information regarding name, date of birth, or initials of dates reflecting medication was given that day. Additionally, there is no current centrally stored medication log for residents in care. The Director stated that due to staffing issues, she is aware some records are not up to date but is working towards updating the records at the moment. Based on document review and interviews conducted, this allegation is substantiated at this time.

Report delivered. Exit interview conducted. Appeal rights issued and deficiencies cited, see 9099-D page.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4