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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610363
Report Date: 12/19/2023
Date Signed: 01/11/2024 09:39:43 AM

Substantiated


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
12/14/2023 and conducted by Evaluator Huma Rahimi
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20231214153230
FACILITY NAME:AAA ROYAL SENIOR LIVING FACILITYFACILITY NUMBER:
197610363
ADMINISTRATOR:SHCHERBA, SLAVAFACILITY TYPE:
740
ADDRESS:6214 BECKFORD AVETELEPHONE:
(818) 609-0117
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 6DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide adequate ALWP accommodations to resident in care
INVESTIGATION FINDINGS:
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This is an amended report t to clarify the facts of the original report issued 12-19-2023.

At 9:40 a.m. Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with Vanissa Campbell, Staff #1 (S1), who granted access to the facility upon arrival. The Administrator, Amy Esrtsian, arrived shortly after and LPA explained the reason for the visit.
Entrance interview conducted.

At 10:00am, LPA requested copies of documentation which include, but not limited to Admission Agreement dated 11/30/2022 and Appraisal Needs and Services Plan. At 10:15 am, LPA conducted a physical plant tour. From 10:30am – 11:20am, LPA interviewed the Administrator, two (2) staff, and five (5) residents.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 3
Control Number 31-AS-20231214153230
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: 12/19/2023
NARRATIVE
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Allegation:Staff did not provide adequate ALWP accommodations to resident in care

Based on interviews and observations resident # 1 (R1) was moved temporarily from their private room to a shared room due to repairs/remolding without prior written notice on or about 11/15/2023. Per review of R1’s admissions agreement R1 is entitled to a private room.
LPA conducted interviews with the Administrator and staff who admitted to relocating R1 from their own private room to a shared room with another resident from 12-06-2023 to 12-13-2023.
On 12/06/2023, the administrator admits new resident and instead of giving R1 back their original private room as repairs were completed the new resident was given R1’s room. The allegation is substantiated. The Administrator should have returned R1 to their original room once repairs were completed and not given it to the newly admitted.

Deficiency cited on LIC 9099D.
Exit interview conducted.
Appeal rights and copy of this report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20231214153230
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3)Personal Rights of Residents in All Facilities....Residential care facilities for the elderly.... the following personal rights:To be free from punishment...... daily living functions..... eating, sleeping, or elimination.
This requirement is not met as evidence by
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Administrator moved R1 to room # 4 on 12/13/2023. The move was completed prior to completion of the visit.
*****Citation corrected at time of visit******
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Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by not accommodating R1 with their private room after the repair as promised which poses a potential health and safety risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3