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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:24:19 PM

Substantiated


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
05/23/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230523115439
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: 91DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Wilfred "Willie" Guerrero, Resident Services DirectorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not notify Responsible Party of resident's change in condition.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 06/01/2023, Licensing program Analyst (LPA) Mario Leon conducted an unannounced subsequent complaint visit to the facility. LPA was met by Wilfred Guerrero, Resident Services Director, who was informed that this visit was conducted to continue an investigation of the complaint allegations, previously initiated on 05/25/2023.

The investigation consisted of the following:

On 05/25/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit at this facility. LPA Leon toured the facility and interviewed 8 out of 92 residents and 4 staff and one witness. LPA requested and reviewed resident records which consisted of: Medical assessments and internal assessments, Resident appraisals, admission agreements and Identification and Emergency information sheets. LPA also requested and reviewed staff training records and facility records.

Report continues, see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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 11-AS-20230523115439
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: 06/01/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegation: "Staff did not notify Responsible Party of resident's change in condition.” R1’s Physician's Report dated 03/04/2021 indicated that R1 had "mild memory loss" and "depression", Staff interviews and the facility’s internal records indicate unusual behavioral changes in R1 such as being aggressive towards other residents and imposing their religious beliefs towards staff and residents on 05/05/23, 05/08/23, 05/15/23 and 05/16/23, LPA did not observe any evidence that the residents responsible party were contacted during, or immediately after, said incidents. Based on staff interviews, record reviews and observations conducted during this inspection, there is sufficient information to verify the allegation "Staff did not notify Responsible Party of resident's change in condition.". Therefore, the allegation is Substantiated.



Regarding the allegation: “Staff did not seek medical attention for resident in a timely manner.” LPA interviews indicate that, on 05/17/23, witness W1 initiated a tele-health appointment for R1. As a result, R1 was ordered to be sent to the ER by their primary care physician, where R1 was diagnosed having a "manic-episode". Staff interviews and the facility’s internal records indicate unusual behavioral changes in R1 such as being aggressive towards other residents and imposing their religious beliefs towards staff and residents on 05/05/23, 05/08/23, 05/15/23 and 05/16/23. LPA did not observe any evidence that the facility sought medical attention for the resident, R1. Based on interviews and observations, there is a sufficient information to verify the allegation “Staff did not seek medical attention for resident in a timely manner.” Therefore, the allegation is Substantiated.

Deficiencies under Title 22 regulations have been cited, see LIC9099D.

An exit interview was conducted and plans of corrections were developed with Wilfred Guerrero. A copy of this report and appeal rights have been provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230523115439
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
87466
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87466 - Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental…observation reveals unmet needs. When changes such as..losses or deterioration of mental ability..are observed, the licensee..are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This has not been met as evidenced by:
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Resident Services Director, Wilfred Guerrero, agreed to create a plan to ensure that changes to residents are brought to the attention of the resident’s responsible persons. Proof of correction will be submitted to LPA by POC due date at Mario.Leon@DSS.CA.GOV.
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Based on record reviews and interviews conducted, the Licensee failed to ensure that changes to residents are documented and brought to the attention of the resident's physician and the resident's responsible person which poses a potential health, safety and personal rights risk to persons in care.
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Type B
06/08/2023
Section Cited
CCR
87411(d)(5)
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87411 - Personnel Requirements, General
(d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training../..experience shall provide knowledge of..in the following, as appropriate for the job assigned..as evidenced by safe..effective job performance:
(5)Knowledge necessary..recognize early signs of illness and the need for professional help.
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Resident Services Director, Wilfred Guerrero, agreed to create a plan to ensure that all staff have the knowledge necessary in order to recognize early signs of illnesses and the need for professional help, including the need to report physical or mental changes in residents.
Proof of correction will be submitted to LPA by POC due date at Mario.Leon@DSS.CA.GOV.
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This requirement was not met as evidenced by:
Based on record reviews and interviews conducted, the Licensee failed to ensure that staff have the knowledge necessary in order to recognize early signs of R1’s illness and the need for professional help, which poses a potential health, safety and personal rights 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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3