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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 09/03/2025
Date Signed: 09/25/2025 09:08:38 AM

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
08/04/2025 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250804132850
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:
09/03/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:William "Bill" Boles (Executive Director)TIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Facility staff failed to provide proper supervision to the resident.
INVESTIGATION FINDINGS:
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On 09/03/2025 at 8:40am, Licensing Program Analyst (LPA) Zina Brown conducted a unannounced subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, at 9:55am LPA met with William "Bill" Boles (Executive Director) and explained the purpose of the visit.

The investigation consisted of the following: On 08/08/2025 at 8:05am, an initial complaint visit was conducted by the Department. On that date, LPA conducted interviews with Administrator (A1) between 12:50pm - 1:04pm, Staff (S1–S10) between 8:28am - 11:42am, Staff 11 (S11) on 08/14/2025 at 3:04 pm, Staff 12 (S12) on 08/15/2025 at 6:12pm., Staff 13 (S13) on 08/27/2025 at 11:12am, and Residents (R1–R10) between 8:39am - 1:40pm. LPA requested copies of the Resident Roster (dated 07/23/2025), Staff Roster (dated 08/05/2025), LIC 601 Identification and Emergency Information (for R10 – received 08/08/2025), LIC 602A: Medical Assessment for RCFE (for R10 – dated 08/06/2025), Plan of Care for R10 (received 08/08/2025), LIC 9172 Functional Capability Assessment (for R10 – dated 01/24/2011), Admission Agreement (for R10 – dated 05/01/2023), Personal Rights (for R10 – dated 05/01/2023), eMAR Summary (07/2025–08/2025) for R10, PCA Work Schedule (07/28/2025–08/03/2025), & Employee Time Cards for Staff 11 (S11) - Staff 13 (S13) (08/01/2025–08/02/2025).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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-20250804132850
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: 09/03/2025
NARRATIVE
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The investigation revealed the following:

Allegation – Facility staff failed to provide proper supervision to the resident
It was alleged that a resident of Studio Royale wandered from the facility unnoticed and was later found by the Culver City Fire Department near dumpsters, dirty, barefoot, cold, and nonverbal, raising concerns about staff supervision.

On 08/08/2025, between 12:50pm - 1:04pm, LPA interviewed Administrator (A1). A1 stated it was difficult to determine when staff first became aware that Resident 10 (R10) was missing. A1 reported that R10 made her way down the hall of the south building and exited the door adjacent to the dumpster enclosure. A1 also stated that it appeared R10 exited at approximately 1:20am and there's no record of when she returned to the building. A1 also stated R10 does not have dementia and has no previous history of elopement and wandering. On 09/03/2025 at 10:05am, A1 informed LPA, effective as of 08/06/2025, R10 has one on one private care upon R10 returning to the facility from the hospital after the incident that occurred on 08/02/2025.

On 08/08/2025, between 8:28am - 11:42 am, LPA interviewed Staff 1 (S1) through Staff 10 (S10). LPA also interviewed Staff 11 (S11) on 08/14/2025 at 3:04pm, Staff 12 (S12) on 08/15/2025 at 6:12pm, and Staff 13 (S13) on 08/27/2025 at 11:12am regarding the allegation. Of the 13 staff interviewed, 3 out of 10 staff confirmed the allegation. 5 out of 10 staff denied the allegation. 5 out of 10 staff were unaware of the situation. Of the 3 staff who confirmed the allegation, S4 stated the facility become aware of R10 being outside of the community upon the paramedics coming to the facility to have staff identify R10 who was unable to identify themselves. Of the 10 staff who denied the allegation and were unaware of the allegation, the staff stated that they were not schedule to work nor present at the time of the incident occurring.

On 08/08/2025, between 8:39am - 1:40pm, LPA interviewed Resident 1 (R1) through Resident 10 (R10). 9 out of 10 residents denied the allegation. 1 out of 10 residents were unsure about the allegation. Of the 10 residents, the 9 residents who denied the allegation stated not having any knowledge of the allegation occurring while the 1 resident who was unsure of the allegation could not recall the allegation occurring.

Report continues on LIC 9099-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20250804132850
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: 09/03/2025
NARRATIVE
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On 09/02/2025, between 3:10pm - 4:00pm, LPA conducted a records review and observed the following: The Department received the LIC 624 Unusual Incident/Injury Report (dated 08/06/2025) for the incident that occurred on 08/02/2025 at around 6:00am. The report stated R10 was found by the Community Medication Technician lying on the ground near the dumpster across the street from the community. R10 was transported to SoCal Hospital Culver City Emergency Room. The LIC 624 also stated R10 is assessed by the Community Nurse twice a year and as needed for changes in condition, with care plans updated and implemented accordingly. R10’s current plan has been updated as of 08/06/2025 with additional care to meet her needs. The LIC 602A: Medical Assessment for RCFE (for R10 – dated 08/06/2025) on page 5 of 9 under Section 2: Capacity for Self-Care – H. Able to leave facility unsupervised (considering physical or cognitive abilities)is checked “No,” as R10 has a history of multiple falls. However, before the incident that occurred on 08/02/2025, R10’s previous LIC 602A: Medical Assessments (dated 01/08/2024 and 04/25/2023) on page 4 of 6 under Section 14: Mental Condition – Letter K. Able to leave the facility unsupervised was checked “Yes.”

Based on interviews and record reviews conducted, there is not enough evidence to support that facility staff failed to provide proper supervision to the resident. Therefore, the allegation is UNSUBSTANTIATED.

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.


An exit interview was conducted with William "Bill" Boles (Executive Director) and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3