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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197609666
Report Date:
05/07/2022
Date Signed:
05/07/2022 05:16:01 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-20200604152342
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:
05/07/2022
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Estela Avetyan/Director
TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify residents authorized representative of changes in medical conditions.
Staff did not notify residents authorized representative
Staff did not provide admission agreement to resident
Staff did not safeguard residents personal items
Staff did not keep residents information confidential
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA came to the facility and there was no staff or residents present. LPA spoke with the administrator by telephone who stated they had no residents at the location. LPA conducted the visit via facetime.
Staff did not notify residents authorized representative of changes in medical conditions & Staff did not notify residents authorized representative
It is alleged with these two allegations that facility staff did not notify resident #1 (R1) family regarding R1's change in medical condition and notify R1's family regarding R1's care. LPA conducted interviews with R1's family regarding these allegations on 6/9/2020 and 4/9/2022. LPA also interviewed the administrator regarding this allegation on 4/9/22. Information from interviews reveal that on 5/9/2020 R1's family was called regarding R1 needing to go to the hospital due to R1 not feeling well. After R1 went to the hospital on 5/9/2020 R1 never returned to the facility. Based on the information obtained through interviews both of these allegations are deemed Unsubstantiated at this time.
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:
05/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/07/2022
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
2
Control Number
31-AS-20200604152342
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:
05/07/2022
NARRATIVE
1
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4
5
6
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8
9
10
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32
Staff did not provide admission agreement to resident
It is alleged that R1's family was not provided an admission agreement regarding R1 staying at this facility. Interviews were previously conducted with R1's family member on 6/9/2020 and 4/9/2022 regarding this allegation. Facility administrator was also interviewed regarding this allegation. Information from interviews revealed that R1's family never brought R1 into the facility and R1 was placed at this facility by a hospital social worker from Northridge Hospital. R1's family stated they never came to the facility until after R1 passed away to pick up R1's belongings. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Staff did not safeguard residents personal items
It is alleged that when resident # 1(R1) passed away and R1's family came to pick up R1's belongings that specific clothing of R1's was missing. LPA investigated this allegation in complaint control number 31-AS-20200604112027
on 4/9/2022. LPA previously
conducted interviews with R1's family member and the administrator regarding this allegation. LPA obtained and reviewed R1's personal property ledger. Information from interviews revealed that R1's family did not have anything to do with R1's placement at the facility and R1's family had never been to the facility prior to R1's passing. It appears that R1 filled out their personal property list. Based on the information obtained through interviews and documentation there is not enough information to state the facility did not safeguard R1's property therefore this allegation is deemed Unsubstantiated as it was on the other complaint control number 31-AS-20200604112027.
Staff did not keep residents information confidential
It is alleged that the facility did not keep R1's information private. LPA conducted interviews with R1's family and the administrator regarding this allegation. Information from interviews reveal there was no issue with privacy of R1 while R1 was at the facility or was R1's information including medical information shared with anyone it wasn't supposed to be shared with. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted. Copy of report emailed for signature. Hard copy with signature on file.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
05/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/07/2022
LIC9099
(FAS) - (06/04)
Page:
2
of
2