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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 10/27/2020
Date Signed: 11/08/2020 10:46:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20200728115557
FACILITY NAME:STUDIO ROYALEFACILITY NUMBER:
198601566
ADMINISTRATOR:TERRI WEITZMANFACILITY TYPE:
740
ADDRESS:3975 OVERLAND AVENUETELEPHONE:
(310) 836-5854
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:175CENSUS: 92DATE:
10/27/2020
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Terri WeitzmanTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents medications are not being provided as prescribed.
INVESTIGATION FINDINGS:
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This document is an amendment of the document dated 10/27/2020, the prescribing doctor and their staff's private information were removed.
Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Terri Weitzman the facility administrator.
The complaint investigation consisted of the following: On 07/29/2020 LPA Coronel conducted a video call which consisted of a review of outside patio, outside activity area medication room. The LPA requested copies of the Facility Sketch, Personnel Report and Register of Facility Residents. LPA also requested copies of residents R1 and R2’s residents records which included Medication Administration Records and Incident Reports. On 08/03/2020 LPA Coronel conducted telephone interviews with the administrator, medical aide staffs S1 and S2. LPA also conducted an interview with R1’s responsible party. On 08/04/2020 LPA conducted record reviews of R1’s resident records. LPA also conducted telephone interviews with the Administrator, Med Room Supervisor Chanel Lee and 10 out of 98 facility residents. On 08/06/2020 LPA interviewed R1's Prescribing Doctor and the Prescribing Doctors Staff.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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 4
Control Number 11-AS-20200728115557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566
VISIT DATE: 10/27/2020
NARRATIVE
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This document is an amendment of the document dated 10/27/2020, the prescribing doctor and their staff's private information were removed.

The complaint investigation revealed the following:

On 08/03/2020 S1 stated that "R1 would become aggressive when being given medications at bedtime." and “R1 told me that the medication makes R1 feel groggy and lethargic.” S2 stated that: "R1 refused a specific medication at least 4 times in May, more than 5 times in June and around 10 times in July." R1’s responsible party stated that: "They never called me about R1 refusing medications."

On 08/04/2020 During record reviews of R1’s Medication Administration Records (MAR), LPA observed records of R1 continuously refusing a specific medication to be taken at bedtime from 06/20/2020 to 07/15/2020 (25 consecutive days). LPA did not observe any Unusual Incident Reports submitted to Community Care Licensing Division regarding the said refusals. During resident interviews 7 out of 10 residents interviewed did not have issues with medication assistance being provided and 3 out of 10 had issues with medication assistance being provided, R8 stated they missed their medications 3 times at bedtime, R9 stated that they missed their medications at least once a week at bedtime, R1 stated that: “They come in so late, I'm either too sleepy or already asleep.”

On 08/06/2020 the Prescribing Doctor indicated that "I already spoke to Terri about it today. Today I ordered that the medication is to be taken at bedtime as needed.". The Prescribing Doctors Staff indicated that the only documented call received about this refusal was on 07/30/2020 and stated that "We should have been informed at the time of refusal, so the doctor could talk to R1 about it or so adjustments could be made."

Regarding the allegation: “Residents medications are not being provided as prescribed.” Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited, please see LIC 9099D

A telephonic exit interview, Plans of Corrections were reviewed and developed was conducted with Terri Weitzman, and a hard copy of this report and appeal rights were discussed and provided via email for signature.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20200728115557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2020
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care... following:(1) The licensee shall arrange, ...medical and dental care appropriate to the conditions and needs of residents.
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Administrator agrees to develop a plan on arranging routine medical care when residents refuse medications and submit plan of correction by POC due date.
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This requirement was not met as evidenced by: Based on interviews and record reviews conducted, the licensee failed to develop a plan with R1's physician, R1 did not take their medication as ordered for 25 consecutive days, which poses a potential health and safety risk to clients in care.
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Type B
10/30/2020
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed ... and that appropriate assistance is provided ...needs. When changes ... are observed, the licensee shall ensure that such changes are ...brought to the attention of the resident's physician ...any.
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Administrator agrees to develop a plan on informing resident's physician and the resident's responsible person when changes such as refusal of medications are observed and submit the plan of correction by POC due date.
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This requirement was not met as evidenced by: Based on LPA observation, interviews and record reviews conducted, the licensee failed to ensure that staff informs R1’s physician and responsible person that R1 was refusing prescribed medications. Which poses a potential health and safety risk to clients 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20200728115557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2020
Section Cited
CCR
87211(A)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish...following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident...within seven days of the occurrence ... case. (D) Any incident which threatens the welfare, safety or health of any resident, ...resident.
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Administrator agrees to develop a plan on submitting written reports to licensing agency and to the person responsible for the resident within seven days of the occurance of an incident that threatens the health of any resident and submit plan of correction by POC due date.
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This requirement was not met as evidenced by: Based on record reviews conducted, the licensee failed to ensure that R1 refusing their prescribed medication for 25 consecutive days was reported to the licensing agency and to R1's responsible person within seven days of the occurance. Which poses a potential health and safety risk to clients 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4