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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:10:56 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
12/30/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20241230150951
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: 92DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Tamera Gant, Health and Wellness DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not address a resident's change in medical condition
INVESTIGATION FINDINGS:
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On 1/9/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Health and Wellness Director, Tamera Gant and explained the purpose of the visit is to investigate the allegation mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, resident files, Out of the Community list, ID and Emergency Information, Physicians Report, Preplacement Appraisal, California HSE Results, Medication List, Incident Log, Email communications and Progress Notes. LPA interviewed S1 thru S8 and R1 thru R5.

The investigation revealed the following:

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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-20241230150951
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: 01/09/2025
NARRATIVE
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Allegation: Staff did not address a resident's change in medical condition

It was reported that staff is not addressing a residents change in medical condition. LPA Shirley spoke with S-1 and was told that R-1’s care services were updated 9/22/24. Resident was being assisted with showers and dressing. LPA Shirley reviewed progress notes for R-1 which are updated periodically and as needed. LPA Shirley observed that on 11/18/24, hospice came for an evaluation for signs of decline. Hospice stated that they didn’t see any signs of further decline. On 12/13/24, R-1 was discharged from hospice services as resident was doing fine. Per S-1, R-1 has a personal companion to assist her 4 hours per day with day-to-day activities of daily living. Per interview with S-1, resident began refusing to eat, showed signs of becoming weaker and requested to stay in bed. On 12/21/24, per progress notes resident was feeling pain in her leg. Per S-1, R-1 had several falls going to and from the bathroom and transferring in and out of the bed. Per S-1, additional services were placed on the care services for R-1. Per interview with S-1 hospice nurse came for evaluation on 1/4/25 and R-1 was placed back on Kaiser hospice. LPA Shirley observed several communications between staff and a family member requesting to meet. On 1/9/25, during interview S-1 had to leave conference room as R-1’s family member requested a meeting regarding the resident’s care.


LPA interviewed staff-1 thru staff-8 (S-1 thru S-8). LPA ask, does staff address a residents change in medical condition? Of those interviewed, 8 out of 8 answered yes. LPA interviewed resident -1 thru resident - 5 (R-1 thru R-5). LPA ask, does staff address residents change in medical condition. Of those interviewed, 4 out of 5 answered yes and 1 answered, sometimes. Based on information gathered, LPA did not find sufficient

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241230150951
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: 01/09/2025
NARRATIVE
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evidence to support the allegation “Staff did not address a residents change in medical condition,” therefore this allegation is unsubstantiated.

There were no deficiencies observed during this visit.

LPA Shirley conducted an exit interview, and a copy of this report was signed by the Health and Wellness Director, Tamera Gant.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3