197610363-11-9-2023-31-AS-NGID-CY9TZQ-20231206141040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610363
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:29:50 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
11/08/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20231108143829

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:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amy Eritsian, Designee		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not ensuring the resident is taking medication as prescribed.

INVESTIGATION FINDINGS:

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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 Vanissa Campbell, Staff #1 (S1), who granted access to the facility. Shortly after, Designee and the Licensee of the facility arrived, and LPAs explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 9:40am, LPAs requested resident and staff roster. At 09:50am, LPAs requested copies of pertinent information which include, but not limited to Medication Policy, Centrally Stored Medication and Destruction Records (CSMDR) for Resident #1 (R1) and R2, Staff training etc., relevant to the investigation. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 11:00am – 12:30pm, LPA conducted an interview with the Licensee and Designee, one (1) staff and four (4) residents.
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 5

Control Number 31-AS-20231108143829

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
	VISIT DATE: 11/09/2023

NARRATIVE

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It was reported that the facility Staff are not ensuring the resident is taking medication as prescribed. To investigate this allegation, LPAs conducted an interview with Licensee, Designee and S1. All parties informed LPAs that four (4) out of four (4) residents receive their medications as prescribed and every time the medication is given to the resident, facility staff initials it on a Medication Administration Record (MAR). In addition, LPAs conducted interviews with four (4) out of four (4) residents and all residents confirmed that they receive their medications as prescribed. During today's visit, LPAs reviewed the facility Centrally Stored Medication and Destruction Record (CSMDR) of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPAs observed that two(2) out of two (2) randomly chosen prescribed medications were centrally stored by the facility, however, they were not properly documented on CSMDR. LPAs observed R2’s two (2) medications (Divalproex Sodium and Lithium Carbonate) were prescribed to be administered/given as of 11/01/23, however, both medications were not delivered/received by the facility. Moreover, interview with the Licensee, Designee and S1 confirmed that after acknowledging that the medications were not received, the facility did not report to the Pharmacy, Hospice Agency, Doctor, etc. regarding this matter. Although, two medications were prescribed to R2 as of 11/01/23, LPAs confirmed during todays visit, that R2 missed nine (9) days of prescribed medications, which poses a immediate health and safety risk to residents in care. Based on inspection, record reviews and interviews this allegation is deemed Substantiated.

Deficiency cited on LIC9099-D.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20231108143829

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/10/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will order the missing medications from the pharmacy and notify doctor regarding the incident. Administrator will also submitt an incident report regarding the 9 day medication error.
	8 9 10 11 12 13 14	Based on record reviews and interviews, licensee did not comply with the section above by not assuring that R2's prescibed medications were delivered timely and administered to R2 as prescribed. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agreed to schedule vendorized training for all staff by 11/10/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
11/08/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20231108143829

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:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amy Eritsian, Designee		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff do not clean residents' rooms.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20231108143829

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: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
	VISIT DATE: 11/09/2023

NARRATIVE

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It was reported that the facility Staff do not clean residents room.To investigated this allegation, LPAs conducted an interview with Staff #1 (S1) and were informed that on a daily bases the rooms are cleaned by taking out the trash, fixing the bed (change sheets if needed), dusting and organizing the room. A deep clean is also done on a daily bases, which includes vacuuming the room, cleaning the bathroom, changing the bed sheets, and any other maintenance the room may require. At 10:30am, LPAs toured resident rooms #2, #3 and #4. All the rooms appeared to be clean and free of debris. The rooms appeared to be lived in and they were well maintained. Interviews with four (4) out of four (4) residents confirmed that their rooms are being cleaned daily. Based on interviews and LPAs observation, there is not enough evidence to support the above allegation. Therefore, this allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5