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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:35:25 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/28/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20210728164124
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: 75DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Terri WeitzmanTIME COMPLETED:
02:22 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed to resident.
INVESTIGATION FINDINGS:
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On 08/05/21 Licensing Program Analysts Jade Jordan and Jennifer Jones conducted an unannounced complaint visit regarding the above allegation. The LPA’s were met by Facility Administrator Terri Weitzman. The purpose of the visit was explained.

The investigation consisted of the following: Lpa’s requested pertinent documentation regarding the allegation. (Physicians Report, Medical Administration Record, Resident Roster, Staff Roster) interviews were conducted with 7 residents in care, 2 med technicians and Facility Administrator.

Regarding the Allegation: Facility Staff did not administer medication as prescribed to resident.
LPA’s conducted a file review of the Facilities Digital Medication Administration (MARS) log dated from the Month of November 2020 to current. The documented Mars showed that R1 received Dorzol/TIMOL in each eye twice a day, and was initialed by administering Med tech of the hour.
LPA’s conducted interviews with 6 additional residents in care R2-R6.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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-20210728164124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566
VISIT DATE: 08/05/2021
NARRATIVE
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 R2-R6 generally stated that they Do receive medications at the facility and that they receive medication as prescribed on a daily basis. The Med tech indicated that on 08/02/21 the facility did run out of required eye drops but provided proof of submission to request a refill prior to the medications contents being empty on 07/19/21; 07/26/21, and 08/02/21 to Guardian Pharmacy. The Medication Administration Record only reflects the day of 08/02/21 as the day the R1 did not received prescribed medication, due it not arriving from the pharmacy. Based on LPA Record Review and Interviews the LPA finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated”

Copy of the report was given to the administrator. No citations were given issued during this visit.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2