198601566-10-26-2022-11-AS-UCOL-CLQQ97-20221202105751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:47:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
10/18/2022 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221018105105

FACILITY NAME:	STUDIO ROYALE		FACILITY NUMBER:	198601566
ADMINISTRATOR:	TERRI WEITZMAN		FACILITY TYPE:	740
ADDRESS:	3975 OVERLAND AVENUE		TELEPHONE:	(310) 836-5854
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	175	CENSUS: 100	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Kimberly Eldridge - interim Executive/Chanel Lee - care coordinator medications		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff disclosed resident's personal information to other residents.

INVESTIGATION FINDINGS:

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On 10/26/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Care coordinator medication Chanel Lee, Interim Executive Director Kimberly Eldridge and Vice President Kelly Metz joined on the phone.

The investigation consisted of the following: LPA requested resident roster, staff roster and other service documents. LPA interviewed resident (R1-R10) and staff (S1-S6).

A plant inspection of the facility was conducted.

There were no deficiencies found during any visits.

Investigation revealed:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221018105105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 10/26/2022

NARRATIVE

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Allegation: Staff disclosed resident’s personal information to other residents.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation.

LPA conducted interviews with residents (R1-R10). 7 of 10 residents interviewed did not have any concerns with an incident where staff disclosed resident’s personal information to other residents. LPA interviewed staff (S1-S6). 6 of 6 staff interviewed did not have any concerns with an incident where staff disclosed resident’s personal information to other residents. Staff (S3-S6) interviewed have not heard of any resident being evicted or any resident or staff sharing information about any resident being evicted. Staff (S1) did serve a 30 day pay or quit notice to resident (R1) and was served in confidence. El Segundo Region received 30 day pay or quit notice to resident (R1) and was documented on 09/29/22. LPA received a copy during the visit conducted on 10/26/22.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with interim Executive Director Kimberly Eldridge and a hard copy was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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