198601566-3-7-2024-11-AS-MVAO-D3CTPM-20240314145434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:10:29 AM

Substantiated

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
12/07/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231207091941

FACILITY NAME:	STUDIO ROYALE		FACILITY NUMBER:	198601566
ADMINISTRATOR:	LEWIS,ERNEST D.		FACILITY TYPE:	740
ADDRESS:	3975 OVERLAND AVENUE		TELEPHONE:	(310) 836-5854
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	175	CENSUS: 86	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ernest "EJ" Lewis, Executive Director		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Facility staff mismanaged residents' medications

INVESTIGATION FINDINGS:

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On 3/7/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to Executive Director, Ernest (EJ) Lewis and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents -1 through residents - 9 (R-1 - R-9), and staff -1 through staff – 6 (S-1 – S-6). A review of resident files, MARs logs, incident reports for last 6 months and any records associated with this complaint was conducted. A tour of the facility was performed.

The investigation revealed the following:
Con’d on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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-20231207091941

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: 03/07/2024

NARRATIVE

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Allegation : Facility staff mismanaged residents' medications.

It is alleged that residents have missed medications and that some have not had their prescriptions filled. On 12/14/2023 LPA Shirley reviewed facility records. LPA received copy of eMAR for resident 1 – resident 4 (R1-R4). LPA Shirley noted that most R1, R2 and R3 missed several days of medications. LPA requested and received incident reports from the last 6 months. Upon record review, LPA did not observe any report notifying CCLD of the pharmacy switch and issues dispensing medications. On 12/14/2023 LPA Shirley spoke to facility Administrator Ernest Lewis regarding the allegations. During interview administrator stated facility implemented a new system for dispensing medications as the facility had a change in pharmacy. Administrator further stated that several of the med techs could not access the new program, so there was a manual medication log being used. LPA Shirley requested copies of the facilities manual log. On 12/19/2023 LPA Shirley called to follow-up on the manual mediation logs and was told by Administrator Ernest Lewis that he could not obtain logs. As of 3/7/2024, no copies of the manual logs have been provided.

LPA interviewed Staff 1 to Staff 6 (S1-S6). LPA asked staff if there is a history of missed medications at the facility. Of those interviewed, 4 out of 6 indicated there is no history. LPA interviewed resident 1 to resident 9, (R1 to R9), R10 was not available. LPA ask residents, “Have you ever missed getting your medication?” Of those interviewed, 5 out of 9 had no issues.

Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231207091941

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: 03/07/2024

NARRATIVE

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Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 9099-D.

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Director Ernest (EJ) Lewis whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20231207091941

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/07/2024 Section Cited CCR 87465(6)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care 6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.	1 2 3 4 5 6 7	Licensee will submit plan informing the department medication training has been peformed with all staff. A written proof of correction must included date, time and particpants names. Correction must be submitted by due date: 03/21/24 to LPA's email: felisa.shirley@dss.ca.gov
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records reviews, the facility staff failed to make accurate records for prescribed medications for (R3). This violation poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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