198601566-4-4-2024-11-AS-EMAZ-D4GRTP-20240419131842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 04/04/2024
Date Signed: 04/04/2024 03:36:18 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, 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
10/18/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20231018150058

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:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:			TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident's invoice statement is not correct
Staff would not give an itemized invoice to resident
Staff threatened resident with eviction

INVESTIGATION FINDINGS:

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On 04/04/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent complaint visit to the facility listed above. During today’s visit LPA met with Health and Wellness Director, Tamera Grant, and the purpose of today’s visit was explained. We were later joined by Executive Director, EJ Lewis.

During todays visit LPA toured the facility, interviewed Staff (S2-S8), and interviewed Residents (R7-R11).
During a previous visit on 10/25/23, LPA toured the facility, interviewed staff (S1), interviewed residents (R1-R6), and received documents pertinent to the investigation. The documents include a Staff Roster, Resident Roster, Admission Agreement, Billing Statements, Itemized Billing, Needs and Service Plans, and Pre-Appraisal.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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 5

Control Number 11-AS-20231018150058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 04/04/2024

NARRATIVE

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Allegation: Resident's invoice statement is not correct
The allegation alleges that a resident pays their rent every month even when the rent goes up, and they are unsure how they owe a certain amount.
During record review, LPA received and reviewed R1’s Resident Detail (Summary) Ledger from July 2021 through November 2023. LPA observed a charge of $72 in March 2023 and a charge of $156 in April 2023 for room service. On the Ledger, LPA observed the charge was rolled over every month there after as an unpaid balance. During an interview with resident R1, LPA asked if they were informed of what the additional charge was for, they stated some months back they were informed by management their meals would be delivered to their room. R1 stated they were not informed of the reason it was going to be delivered when R1 usually would go to the kitchen at 3:30pm and get both lunch and dinner and would take it back to their room. R1 stated they did not agree to being charged for the tray delivery service and accepted the service per their request. Additionally in the interview R1 stated they met with the new administrator on 10/18/34 regarding the charge and told them they were not going to pay for something they did not request. R1 stated the issue was resolved and they removed the charges on 10/18/23. During interviews with Residents R1-R11, LPA asked if they had any issues with their monthly billing statement, nine (9) out of eleven (11), stated they have had no issues with their monthly billing statement. During an interview with S1, LPA asked if they knew the reason why R1 was provided with tray service, S1 stated they did not know the reason why R1 was provided with tray service due to S1 was not working at the facility during that time. During interviews with Staff S1-S8, were asked what monthly rate residents are charged, eight (8) out of eight (8)

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20231018150058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 04/04/2024

NARRATIVE

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stated they are charged based on single or double occupancy room and the level of care they require and are provided with.
During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff would not give an itemized invoice to resident

The allegation alleges that the resident requested an itemized invoice of services and charges showing where the additional charge is from, and the facility is not providing the information.
During resident file review, LPA received and reviewed a copy of R1’s itemized billing statement. S1 reviewed the invoice with LPA and broke down the charges. During an interview with Staff S1-S8, LPA asked if residents are provided with an itemized billing statement if they request it, eight (8) out of eight (8) stated if a resident or responsible party request an itemized receipt they are provided with a copy. Additionally, S1 stated they invite residents and the responsible party to come by their office and they will break it down and review each charge with them. During interviews with Resident R1-R11, LPA asked if they receive an itemized billing statement when requested, eight (8) out of eleven (11) stated they have had no issues with receiving an itemized billing statement. Additionally, R1 stated they did eventually receive an itemized billing statement and the Executive Director reviewed it with them and they were able to discuss the charges in question.
During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid,

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231018150058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 04/04/2024

NARRATIVE

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there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff threatened resident with eviction

The allegation alleges that facility staff threatened to evict resident if they do not pay the amount owed.
During document review, LPA received and reviewed all eviction notices given to residents in the past 3 months. LPA observed all eviction notices reviewed met Title 22 regulations and Community Care Licensing had received notices of these evictions. During an interview with Resident R1-R11, LPA asked if they have received an eviction notice or have been threatened with eviction if they do not pay full amount due, ten (10) out of eleven (11) stated they have not received an eviction notice or been threatened with eviction and if you do owe a balance the facility is willing to work with you to get it paid. During an interview with R1 they stated they were told by S1 that if the unpaid balance is not brought up to date could be grounds for evection. During an interview with S1, they stated they informed R1 of the amount due with a letter asking to bring the account up to date and if they are not able to then meet with S1 and see what they could do. S1 stated they reviewed the charges with R1 and informed them if it is not brought up to date it could be grounds for evection as specified in R1s Admission Agreement. LPA received and reviewed a copy of R1s Admission Agreement, that stated on page 4 “The facility may, upon thirty (30) days’ written notice to the resident, terminate this agreement for any of the following reasons: 1. For nonpayment of monthly rate with ten (10) days after due date.”

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231018150058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 04/04/2024

NARRATIVE

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During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

LPA did not observe or cite any deficiencies during today’s visit.

An exit interview was conducted with Executive Director, EJ Lewis and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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