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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881033
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:49:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230111170820
FACILITY NAME:ROYALTY SENIOR LIVINGFACILITY NUMBER:
331881033
ADMINISTRATOR:RILEY, TA'NEISHAFACILITY TYPE:
740
ADDRESS:10104 KINGS CTTELEPHONE:
(951) 416-1064
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 6DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ta'Neisha Riley, Administrator TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not provide access to a resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to initiate a complaint investigation regarding the above-mentioned allegation. LPA Prieto met with administrator Ta'Neisha Riley who states that records were requested for client #1 (C1) by C1's responsible party and their designee. Riley states that there request was received, but there was a delay in filling the request. Riley understands that the timeframe of such request was not met. Riley is still in the process of filling the request to provide resident records,

Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 56-AS-20230111170820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ROYALTY SENIOR LIVING
FACILITY NUMBER: 331881033
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2023
Section Cited
CCR
87468(a)(b)(1)
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PERSONAL RIGHTS
Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
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Administrator to produce resident records to the designated party by 01/14/2023.
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This was not met as evidenced by: Administrator admission of not being able to produce client documentation as required by regulation
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2