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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601566
Report Date: 11/09/2021
Date Signed: 11/12/2021 08:13:18 AM

Substantiated


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
11/04/2021 and conducted by Evaluator Pamela Bunker
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211104104311
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: 90DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Terri WeitzmanTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not keeping resident room free from pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 09, 2021. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Executive Director (ED) Terri Weitzman. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-5 (S1-5) and residents 2-9 (R2-9). LPA Bunker asked questions relevant to the nature of the complaint. Ms. Weitzman and LPA Bunker toured the resident room. LPA Bunker requested and observed AMEN Pest Control invoices for monthly service dated 07/06/2021, 08/05/2021, 08/06/2021, 09/02/2021, 10/07/2021, and 11/03/2021. AMEN Pest Control invoice dated 11/03/2021 indicated initial roach cleanout for units 157, 257, 159. On 08/05/2021, 09/02/2021, and 10/07/2021, AMEN Pest Control reported flies in the kitchen and dining room. Also, treat the bathroom that's by the kitchen.
Continued LIC9099-C page #2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 6
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
11/04/2021 and conducted by Evaluator Pamela Bunker
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211104104311

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: 90DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Terri WeitzmanTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident not administered medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 09, 2021. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Executive Director (ED) Terri Weitzman. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-5 (S1-5) and residents 2-9 (R2-9). LPA Bunker asked questions relevant to the nature of the complaint. LPA Bunker requested pertinent documentation regarding the above allegation. ED Ms. Weitzman and LPA Bunker toured the medication room, observed the resident’s medication and MARs. Administration records, documentation, and observation of R1 records observed indicated the facility Med Techs administer R1's medications correctly according to R1's physician's order.
See continued LIC9099-C page #2



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20211104104311
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: 11/09/2021
NARRATIVE
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Continued LIC9099-C page #2

Allegation #2: Resident not administered medication as prescribed.
Staff and residents interviewed stated residents receive their medications at the facility as prescribed daily. LPA conducted a file review of the Facilities Digital Medication Administration (MARS). The documented Mars showed that R1 received Simbrinza 1%-0.2%, instill one (1) drop in the right eye twice a day, and Systane Complete 0.6% instill one (1) drop in each eye twice daily and was initialed by administering Med Tech of the hours. Staff stated once ordered by the resident's physician the medication is given according to the physician's directions.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC 9099-A, LIC 9099-C, and Confidential Names LIC 811 was provided to Administrator Terri Weitzman

There were no deficiencies cited.

Exit interview conducted
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20211104104311
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: 11/09/2021
NARRATIVE
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Continued LIC9099-C page #2

Allegation #1: Staff not keeping resident room free from pests.

Staff 1-5 (S1-5) and residents 2-9 (R2-9) interviewed stated if they notice any pest staff will contact an exterminator immediately. R2-9 stated they are happy here, the staff goes out of their way to provide excellent care to them, and they have not observed any pests in their rooms or throughout the facility. Staff stated they self-reported the incident regarding roaches in three of the rooms, and flies in the kitchen, dining room, and one bathroom near the kitchen prior to the complaint. Staff stated AMEN Pest Control comes to the facility monthly and sometimes twice a month to prevent the incident from occurring. Staff agrees AMEN Pest Control invoice dated 11/03/2021 indicated initial roach cleanout for units 157, 257, 159. However, there were no roaches mentioned in R1’s unit 158. On 08/05/2021, 09/02/2021, and 10/07/2021, there were flies in the kitchen, dining room, and one bathroom that’s by the kitchen was treated for flies. During today’s visit, we did not observe any cockroaches or cockroach feces in R1’s unit. There were no cockroaches in the fridge, bathroom, dresser, TV, and dishes. We did not observe any roaches or flies in the facility.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal rights were discussed, and copies of LIC9099, LIC9099-C, and LIC9099-D was provided to the
Executive Director (ED) Terri Weitzman.

Exit interview conducted.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20211104104311
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
CCR
87303(a)
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87303 (a) Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Deficiency corrected prior to today's visit. Incident self-reported by the facility.
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On 11/03/2021 AMEN Pest Control indicated initial roach cleanout for units 157, 257, 159, and on 08/05/2021, 09/02/2021, and 10/07/2021, there were flies in the facility kitchen, dining room, and one bathroom.
Which poses a potential health, safety, or personal rights risk to residents in care
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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: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Pamela BunkerTELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6