198601566-6-19-2024-11-AS-SCIS-D6W22X-20240705170128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:40:55 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
05/01/2024 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240501111302

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: 94	DATE:	06/19/2024
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Tamera Gant		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is prohibiting resident from receiving private care of their own choosing.
Facility did not report an incident involving resident as necessary.

INVESTIGATION FINDINGS:

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On 06/19/24, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit at this facility. LPA Gonzalez met with Tamara Gant, Health and Wellness Director, and the purpose of today's visit was explained.

The investigation consisted of the following: On 05/08/24, LPA Gonzalez obtained a copy of the Resident Roster, Staff Roster, Physician’s Reports, Admission Agreement, Preplacement Appraisal Information, and Care Plan, interviewed staff #1- staff #4 (S1-S5), and attempted to interview Witness #1 (W1). On 06/19/24 LPA obtained the Resident Roster, interviewed residents #1-#9 (R1-R9), and attempted to interview W1.

Investigation revealed the following:

Continued on LIC809-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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-20240501111302

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: 06/19/2024

NARRATIVE

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Allegation: Facility is prohibiting resident from receiving private care of their own choosing. It is alleged that a private care representative was denied access to facility residents.

On 05/08/24, LPA interviewed Tamera Gant, Health, and Wellness Director. Interview revealed that there had been two incidents with an Occupational Therapist who was rude and confrontational towards her. She then had to call the Occupational Therapist’s boss and advised them of their behavior and the confrontation, and that they were no longer allowed in the facility. On 05/08/24 LPA Gonzalez interviewed S1-S5. LPA asked staff if they had witnessed an altercation between the Health and Wellness Director and an Occupational Therapist. 3 out of 5 staff stated that they had not witnessed any altercation. LPA asked staff if they prohibit residents from receiving private care of their own choosing. 5 out 5 staff reported the facility does not prohibit residents from getting treatment from someone of their own choosing. Furthermore, LPA called and attempted to speak with Paul Kim (Occupational Therapists boss) on 05/08/24 and on 06/19/24 but was not able to establish contact. On 06/19/24 LPA interviewed R1-R9. LPA asked residents if they are allowed to choose their own private care. 8 out 9 residents interviewed reported that they are allowed to choose their own private care.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED.

Allegation: Facility did not report an incident involving resident as necessary.
It is alleged that the facility is not reporting incidents as required when the residents fall or get injured.

On 05/08/24, LPA interviewed Tamera Gant, Health, and Wellness Director. Interview revealed that there was no evidence of a fall or an injury for R1 during the dates of 04/17/24 – 04/24/24. She stated that resident did have a scratch above her eye due to the residents’ long nails, which staff cleaned and put a band aid over the scratch. No incident report was made due to it being a small surface scratch. On 05/08/24 LPA Gonzalez interviewed S1-S5. LPA asked staff do they report an incident when a resident falls or gets hurt. 5 out of 5 staff stated that the facility reports all incidents including falls and or injuries when needed. On 06/19/24 LPA Gonzalez interviewed R1-R9.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240501111302

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: 06/19/2024

NARRATIVE

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LPA asked residents what the procedure is when residents fall or get hurt. 5 out of 9 residents stated that they pull on their call button string, and staff arrive shortly after. 9 out of 9 residents stated that they are satisfied with the facility and the services being provided to them.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of the report was given to Tamera Gant, Health and Wellness Director.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

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