565800734-9-11-2020-29-AS-DPEA-BTCQ79-20200911115445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 09/11/2020
Date Signed: 09/11/2020 11:55:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILLCREST ROYALE		FACILITY NUMBER:	565800734
ADMINISTRATOR:	INGA JAKOBOVICH		FACILITY TYPE:	740
ADDRESS:	190 EAST HILLCREST DRIVE		TELEPHONE:	(805) 371-0035
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	145	CENSUS: 95	DATE:	09/11/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Marian Rubinstein		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Desaree Perera initiated a Case Management - Incident visit. The purpose of this visit is to conclude an investigation initiated by LPA Perera during a Case Management – Incident visit conducted on 08/05/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays visit was conducted telephonically with Marian Rubinstein at 11:25am. Entrance interview conducted. On 07/31/2020, the department received an incident report reflecting that on 07/30/2020, at approximately 8:30pm, the facility staff received a call by the family of Resident #1 (R1) reporting that staff #1 (S1) inappropriately touched R1. Investigator Joseph Balarie from Community Care Licensing Division’s Investigation’s Branch (IB) conducted this investigation. LPA Perera conducted a telephone interview with the administrator on 08/04/2020 at 1:12pm to obtain additional information regarding the incident. During the initial visit conducted on 08/05/2020, the LPA conducted a tour of the physical plant at 11:24am and requested pertinent documentation relating to the incident at 11:45am. During the course of the investigation, Investigator Balarie conducted interviews with facility staff including but not limited to administrator and S1 on 08/10/2020 at 10:00am, 08/13/2020 at 10:15am and between 1:00pm and 1:11pm. Continued LIC809-C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILLCREST ROYALE	FACILITY NUMBER: 565800734
	VISIT DATE: 09/11/2020

NARRATIVE

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On 08/06/2020 at 1:24pm interviews were conducted with family of R1 and on 08/10/2020 at 1:40pm, Investigator Balarie conducted an interview with R1. Furthermore, Investigator Balarie also obtained and reviewed the police report from the Ventura County Sheriff’s Department and the facility video surveillance relating to the incident.

Information gathered during the course of the investigation revealed that S1 entered the room of R1 at approximately 7:27pm with a food tray and exits room at 7:31pm. S1 then comes back to R1s room at 7:34pm with ice cream and exits the room at 7:37pm. Interviews conducted revealed that at approximately 8:15pm, S2 received a call from the family of R1 stating that R1 was distraught and informed that R1 had being sexually assaulted by S1. Paramedics and police were immediately contacted to assess R1. R1 did not have any physical injuries therefore no medical attention was obtained. Based on all the information gathered, it was revealed that R1’s interviews with various deputy officers and investigator varied at each account and contained multiple inconsistencies of the alleged incident. Moreover, S1 denied the alleged incident and the deputies did not find sufficient evidence to arrest S1. Based on all information gathered, there is insufficient evidence to determine that R1 was sexually assaulted by S1.

Exit interview conducted/ No citations issued/ A copy of report was report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020

LIC809 (FAS) - (06/04)

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