197609666-4-8-2022-31-AS-NGID-CDESB7-20220412134323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609666
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:43:40 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
06/04/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200604112027

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: 5	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Pauline Dache		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Questionable Death
Licensee did not report changes in resident's medical condition to his responsible person.
Facility mismanaged resident's medications.
Facility did not safeguard resident's personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
It is alleged that resident #1 medications were possibly mismanaged which may have contributed to R1’s death.
On 06-04-2020 a complaint was received for the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch (IB) to subpoena medical records and death certificate.
Due to the situation of the Corona Virus (COVID-19) the department initiated the complaint by phone, June 15,2020. The Administrator was contacted and interviewed, copies of relevant documentation requested, and collected by email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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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Control Number 31-AS-20200604112027

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: 04/08/2022

NARRATIVE

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The investigation consisted of but not limited to interviews with facility staff and witnesses on 6/09/2020. Review of the resident’s(R1) facility file and medical records which were subpoenaed 6/22/2020.

Information from interviews and record review reveal that R1 came into the facility on 3/5/2020 due to R1’s health declining and R1’s family not being able to take care of R1. On 5/9/20 R1 was not feeling well therefore was transported to Los Angeles Community Hospital. R1 never left the hospital and passed away on 5/25/20. A review of R1’s death certificate reveals that R1 passed away due to cardiac arrest and heart failure. Information obtained through interviews and record review does not indicate that R1 passed away due to facility neglect or mismanagement of medication. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Licensee did not report changes in resident's medical condition to his responsible person.

It is alleged that facility did not contact R1's responsible person regarding a change in R1's medical condition which caused R1 to be hospitalized. Interviews were conducted with R1's responsible person on 6/09/2020. When interviewed R1's responsible person stated that they received a phone call on 5/9/2020 stating R1 was not feeling well and that R1 needed to go to the hospital. After R1 was sent to the hospital on 5/9/2020, R1 never returned to the facility. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Facility mismanaged resident's medications.
It is alleged that facility mismanaged R1's medications and caused R1 to be hospitalized. Investigation consisted of interviews with facility staff and R1's responsible person on 6/9/2020. R1's medical records were obtained and reviewed. Information from interviews and record review show that R1 was not hospitalized due to a mismanagement in R1's medications. Based on the information obtained through interviews and documentation review this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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