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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:50:00 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
08/06/2020 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200806094745
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: 5DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Pauline DacheTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Lack of care/supervision resulted to serious bodily injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit. LPA spoke with administrator Estela Avetyan by telephone and explained the reason for this visit. This complaint was referred to accepted by the Investigations Branch (IB). IB Investigator Jose Santana conducted the investigation.

It is alleged that resident #1 (R1) had a fall and fractured their hip due to neglect by facility staff. Investigation consisted of interviews with R1, facility staff, and facility residents on 8/13/2020 and 8/20/2020. R1’s facility file which included medical information was also obtained and reviewed. Information obtained from interviews revealed that while R1 was at the facility they would walk around on their own. R1’s physician report dated 6/30/2020 also indicated that R1 was ambulatory. While R1 did have a fall in front of the facility there is not enough information to state that lack of care and supervision contributed to R1 having the fall, therefore this allegation is deemed unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 3
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
08/06/2020 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200806094745

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: DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
R1 did not receive timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit. This complaint was referred to accepted by the Investigations Branch (IB). IB Investigator Jose Santana conducted the investigation.
It is alleged that R1 had a fall in front of the facility and facility failed to provide timely medical treatment for R1. Interviews were conducted with R1, facility staff, residents, and R1’s responsible person on 8/13/2020 and 8/20/2020. Interviews from residents and staff indicate that facility staff # 1 (S1) was aware that R1 suffered a fall in front of the facility. S1 denies that they witnessed R1 fall. However, caregiver interviews reveal that R1 had an issue with their lower extremities and had difficulty walking, but staff made no effort to have R1 evaluated for their change in condition with difficulty walking.

Based on the information obtained this allegation is deemed substantiated. Deficiency cited on LIC 9099 D. A copy of the report was issued. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200806094745
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: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
87466
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Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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Licensee, Administrators will schedule and attend 1 hour vendorized training related to the cited section.
1) Verification of the scheduled training with the credentials of the trainer by 3/30/2022
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Based on interviews conducted facility staff observed R1 had issues with their lower extremities but did not ensure R1 received the proper assistance which posed an immediate health and safety issue to 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3