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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:39:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2024 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20241022090726
FACILITY NAME:STUDIO ROYALEFACILITY NUMBER:
198601566
ADMINISTRATOR:LEWIS,ERNEST D.FACILITY TYPE:
740
ADDRESS:3975 OVERLAND AVENUETELEPHONE:
(310) 836-5854
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:175CENSUS: 90DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:TAMERA GANTTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not prevent resident from choking another resident.
INVESTIGATION FINDINGS:
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On 10/30/2024, the department conducted a complaint investigation at the above facility to address the following allegation. The department met with Health Wellness Nurse Director Tamera Gant and explained the purpose of the visit. The department conducted interviews, reviewed resident records, and requested copies of supporting documents.

The investigation consisted of the following: The department interviews five staff members 1- 5(S1-S5) and six residents 1-6 (R1-R6). The department asked questions relevant to the nature of the complaint. During the course of the investigation, the department toured the first floor of the facility building to check for health and safety threats of residents. The department requested the following supporting documents for two residents (R1-R2) including Physician’s report, medical records, admission agreement, identification and emergency information, medication log, medication administration records (MARs) medical assessment, consent form, and appraisal/needs and services plan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 2
Control Number 11-AS-20241022090726
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566
VISIT DATE: 10/30/2024
NARRATIVE
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Allegation: Staff did not prevent resident from choking another resident.

Regarding the allegation "Staff did not prevent resident from choking another resident" it is being alleged that the roommate of a resident choked the other resident while sharing the same room.

On 10/30/2024, five out of five staff (S1-S5) interviews indicated that the choking incident never happened and when a resident complains about a roommate, they make sure to talk with other roommate about the concern. Interview with the Health Wellness Nurse Director indicated that on 10/21/24 9:47 PM, the facility was contacted by a resident’s family member about the incident through emails. On 10/22/24 10:51 AM, the facility and family member worked on a solution to the problem. The Health Wellness Nurse Director indicated that rooms are constantly monitored in the middle of the night and the Health Wellness Nurse Director observed a resident say someone was trying to chock him/her. When they checked resident was a sleep. On 10/22/24, 1:48 PM, the facility removed Resident #2 (R2) from resident #1 (R1’s) room. five out six residents (R1-R6), interviews indicated that when there is a resident-on-resident altercation, staff are fast to assist and resolved the issue. One out six resident interviews indicated that the facility needs to stop residents form yelling at one another in the exercise room, though the trainer resolves the issue quickly.

Based on the interviews, records reviewed there was not enough sufficient of 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.

There were no deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2