331881033-11-27-2023-56-AS-KCLS-CY3PWS-20231130104113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881033
Report Date: 05/04/2023
Date Signed: 11/27/2023 03:29:26 PM

Unsubstantiated

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
05/01/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230501085745

FACILITY NAME:	ROYALTY SENIOR LIVING		FACILITY NUMBER:	331881033
ADMINISTRATOR:	RILEY, TA'NEISHA		FACILITY TYPE:	740
ADDRESS:	10104 KINGS CT		TELEPHONE:	(951) 416-1064
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	92509
CAPACITY:	6	CENSUS: 5	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Ta'Neisha Riley, Administrator		TIME COMPLETED:	11:39 AM

ALLEGATION(S):

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Staff intervened with resident's representative's right to participate in decision-making regarding the care and services to be provided to the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation for the above-named allegation. LPA met with Administrator Ta'Neisha Riley to discuss the elements of the complaint. Regarding the allegation, Staff intervened with resident's representative's right to participate in decision-making regarding the care and services to be provided to the resident; interview with resident #1 (R1), in question, reveals the authorized representative was present during a doctor's visit with R1. R1 did stated that the authorized representative, as well as the facility administrator were included during a medical evaluation. Interview with Administrator Riley also revealed that all parties were physically present during the resident evaluation as well as confirming appointment dates and locations prior to evaluations. Documentation was obtained confirming the date and location of R1's medical evaluation.

Based on the information obtained there is not enough evidence that staff intervened with resident's representative's right to participate in decision-making regarding the care and services to be provided to the resident. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and administrator Riley and a copy was left at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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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