198601566-6-2-2023-11-AS-MVAO-CTMN97-20230711101529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:36:44 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
05/31/2023 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230531134049

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: 91	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Wilfredo Guerrero-Health Wellness Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is not meeting the needs of the resident in care.

INVESTIGATION FINDINGS:

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On 6/2/2023 Licensing Program Analysts (LPAs) Ernand Dabuet and Alfonso Iniguez conducted an unannounced Initial Complaint Visit at the facility named above, LPAs meet with wellness director Wilfredo Guerrero and the purpose of this visit was explain to him.

Investigation consisted of the following:

LPAs and Wellnes Director did a physical toured of the facility.
LPAs requested the following documentaion: personnel report, resident's roster and 3 clients charts.
LPA's Interview the folowing people: 4 staff members, 9 residents and 1 witness.

CONTINUE on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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-20230531134049

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: 06/02/2023

NARRATIVE

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Investigation revealed the following:

Allegation: Facility is not meeting the needs of the resident in care.

It is alleged that the facility called 911 to transport Resident R#1 to the hospital for non-urgent medical needs. During this investigation, LPA Dabuet and Iniguez interviewed Residents (R#1-R#9), Staff (S#1-S#4), Responsible Party (W#1) for R#1, and the Wilfredo Guerrero/ Director of Wellness (S#1). Based on interviews with W#1 and S#1, LPA found that R#1 required immediate medical assistance on 5/30/2023. R1’s Responsible Party (W#1) was present on 5/30/2023 and observed R#1 was experiencing symptoms of illness. W#1 contacted R#1’s hospital and was given direction to have R#1 transported to the hospital by ambulance due to symptoms described. The facility placed the call to 911 and R#1 was assessed when EMS arrived. EMS conducted a medical evaluation and determined that R#1’s condition did not require a hospital visit. W#1 insisted EMS transport R#1 to the hospital based on the direction given by medical personnel at R#1’s hospital. R#1 was then transported to the hospital by EMS and assessed upon arrival. On 5/30/2023, the facility was contacted by a hospital representative after R1’s assessment and informed that R#1 was ready for discharge. The hospital representative reported that R#1 was not in need of medical attention based on the medical evaluation performed and should not have been sent to the hospital. During this discussion, S#1 requested the hospital complete a Physicians Report (LIC 602) prior to R#1’s discharge to confirm the facility remains an appropriate placement. On 6/2/2023, R#1 was discharged from the hospital. The hospital refused to provide a completed Physician’s Report to the facility, for R#1, prior discharge. LPA Dabuet and Iniguez conducted an interview with R#1. R#1 was unable to recall experiencing illness on 5/30/2023 and unable to offer details regarding health. The facility has plans for R#1’s primary physician to conduct a medical evaluation during the week of 6/5/2023 – 6/9/2023. LPA’s conducted interviews with S#1-S#4 reported when a change in a Resident’s condition is observed, the information is reported, and a health assessment is conducted to determine the needs of the Residents. LPA’s interviewed R#1-R#9. The Residents interviewed reported the facility is meeting their daily needs and reported no concerns related to the supports provided. Based on interviews conducted and records reviewed, LPA’s were unable to obtain sufficient evidence to support the above mentioned allegation.

Continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230531134049

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: 06/02/2023

NARRATIVE

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Unsubstantiated: “Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. California Code of Regulations.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Director of Wellness Wilfredo Guerrero.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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