197610363-11-8-2023-31-AS-NGID-CY3RK2-20231130120445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610363
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:38:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
11/01/2023 and conducted by Evaluator Huma Rahimi

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231101104055

FACILITY NAME:	AAA ROYAL SENIOR LIVING FACILITY		FACILITY NUMBER:	197610363
ADMINISTRATOR:	SHCHERBA, SLAVA		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amy Eritsian, Admin Designee		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff refused to provide meals to resident in care
Staff did not treat resident with respect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 9:30 am, Licensing Program Analysts (LPAs) Angela Panushkina, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with Amy Eritsian and Kristina and LPAs explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 9:45am, LPAs requested resident and staff roster. At 10:50am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Staff training etc., relevant to the investigation. At approximately 11:55am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11 am – 12:30pm, LPA interviewed the Licensee and Administrator designee, one (1) staff and four (4) residents.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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-20231101104055

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
	VISIT DATE: 11/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff refused to provide meals to resident in care.
It was alleged that staff do not provide meals to residents in care. To investigate this allegation LPAs conducted interviews with Licensee, Designee and one (1) Staff member and were informed that the facility provides three (3) balanced meals and snacks in between and that all residents have full access to the food in the kitchen. Moreover, LPAs were informed that the facility staff will not violate resident's personal rights and will never deny food services to residents. LPAs were also informed that during R1's stay at this facility, R1 would refuse food and request a family member to buy and deliver a fast food every other day. In addition, LPAs conducted interviews with four (4) out of four (4) residents and all four (4) residents denied the above allegation. All residents informed LPAs that the facility always offers/provides three meals and snacks in between and that they do have access to the kitchen and an option to request for an extra food is always available. All residents also denied ever witnessing S1 refusing to provide meals to R1. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.

Allegation:Staff did not treat resident with respect.
It was alleged that the staff do not treat resident with respect. To investigate this allegation LPAs conducted interviews with Licensee and Designee, and one (1) Staff member and were informed that staff always take care of resident with dignity and respect. On the other hand, LPAs were informed that during R1's stay at the facility R1 refused to follow facility house rules and disrespect staff and other residents. During the interview with S1 it was also revealed that on 10/27/23, at 10:40pm, R1 pushed S1 while calling him/her racial slur and 9-1-1 was called and a report was filed. In addition, interviews with four (4) out of four (4) residents revealed that they are being treated very well and with respect by all facility staff members. Interview with R2 revealed that during R1's stay here R2 was very traumatized by R1 approach and behavior. LPAs were informed that R1 would bully R2. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.

No deficiencies cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2