565801653-1-30-2023-29-AS-DPEA-CNM59E-20230131184525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801653
Report Date: 01/27/2023
Date Signed: 01/30/2023 11:08:35 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210211151422

FACILITY NAME:	ROYAL GARDENS OF CAMARILLO		FACILITY NUMBER:	565801653
ADMINISTRATOR:	THOMAS AYER		FACILITY TYPE:	740
ADDRESS:	903 CARMEN DRIVE		TELEPHONE:	(805) 484-2777
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	0	CENSUS: 0	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Tom Ayer		TIME COMPLETED:	03:26 PM

ALLEGATION(S):

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Facility staff is not assisting resident with transfers
Facility raised resident's rate without proper notice
Facility staff have not reappraised resident
Facility is charging resident for services not rendered

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the allegations listed above. Due to a change of ownership effective 05/01/2021, this facility is closed.

Previously, on 02/16/2021, LPA Dulek conducted a virtual initial complaint inspection with the Facility Designee Dylan Hull. During that visit, LPA Dulek conducted a telephone interview with Mr. Hull at 3:18PM, a FaceTime video call was initiated at 4:04PM to conduct a virtual tour of the facility, and LPA requested copies of pertinent documents. Throughout the course of the investigation, LPA interviewed staff and reviewed copies of documents received. The following was then determined:

It was alleged that facility staff are not assisting Resident #1 (R1) with transfers. Review of R1’s care assessment and service plan dated 01/29/2021 revealed that R1 requires transfer assistance “1-2 person Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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 4

Control Number 29-AS-20210211151422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROYAL GARDENS OF CAMARILLO	FACILITY NUMBER: 565801653
	VISIT DATE: 01/27/2023

NARRATIVE

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assist daily. Non-ambulatory. Transfer from bed to chair. Reposition every 2 hours when in bed.” Interview with staff revealed that transfer assistance was provided to the resident daily. Prior to COVID, the facility had daily activities and R1 would visit the Memory Care unit regularly to participate in additional activities. However, the complaint was received during a significant COVID outbreak at the facility. During the time period of 12/23/2020 – 02/17/2021, the facility had multiple residents and staff test positive for COVID-19. As thus, CCL was following up daily with the facility and Ventura County Public Health officials had provided guidance for the facility to follow in order to best mitigate the outbreak and spread of COVID. Guidance provided included closing communal dining room and all group activities. All residents were asked to remain in their rooms as much as possible and COVID positive residents were to remain on isolation in their individual rooms. R1 did test positive during this outbreak. Therefore, at the time of the complaint, the facility was following Public Health’s guidance and residents, including R1, were remaining in their rooms for their own health and safety. Care staff were to utilize full PPE and enter the residents’ rooms to provide ADL assistance to residents. During the time period of the outbreak, as all common activities were closed, R1 would only have required transfers between their bed and wheelchair or in-room chair. Staff interviews revealed that ADL care was provided to R1 in their room and R1 was transferred to their chair or wheelchair, however, R1 required additional supervision when R1 was in their wheelchair due to being a fall risk. Prior to COVID, R1 had a private companion who would remain with R1 during the day while R1 was out of bed. On 01/21/2021, Royal Gardens management sent an email to R1’s responsible party recommending a private 1:1 companion for R1, but R1’s responsible party did not provide a 1:1 companion. Staff indicated they would reposition R1 every 2 hours and would transfer R1 during meal times and when additional staff was available to provide R1 the 1:1 supervision R1 needed when in their wheelchair. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff is not assisting resident with transfers” is deemed UNSUBSTANTIATED at this time.

It was alleged that the facility raised resident’s rate without proper notice. Email communication between the facility management and R1’s responsible party was reviewed. This record review revealed that R1 had a change of condition, therefore Health and Safety Code 1569.657, which states that “the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care,” is applicable. Emails indicate that

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210211151422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROYAL GARDENS OF CAMARILLO	FACILITY NUMBER: 565801653
	VISIT DATE: 01/27/2023

NARRATIVE

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R1 was provided a bill on 01/28/2021 with a due date of 02/01/2021, reflecting the change in R1’s care needs. R1’s care assessment was dated 01/29/2021, and interview revealed that the new level of care was implemented at the end of January, just prior to the billing date. Based on interview and record review, at this time there is insufficient evidence to support the allegation, therefore, the allegation that “facility raised resident’s rate without proper notice” is deemed UNSUBSTANTIATED at this time.

The complaint also alleged that facility staff have not reappraised resident. During the investigation, LPA was provided with a copy of a care assessment and service plan for R1 dated 01/29/2021, which indicates R1 had a change of condition. The care assessment reads “resident needs assistance with feeding…resident, doctor and family communicated on putting resident onto hospice.” Previous care assessment and service plan dated 11/21/2019 did not indicate that R1 required assistance with feeding, only a no salt added/vegetarian diet. Interviews revealed that R1 had a change of condition, and this was communicated to R1’s responsible party. Email communication reviewed between R1’s responsible party and facility staff revealed that R1’s responsible party was given the needs and service plan dated 01/29/2021 and was aware of it’s contents. Per regulation, R1 only required a reappraisal if there had been a change of condition. Staff interview revealed that R1 had been declining and was no longer regularly able to feed themself, therefore a new physician’s report was requested from R1’s physician and facility staff completed a new care assessment. Based on interview and record review, there is insufficient evidence to support the allegation, therefore, the allegation that “facility staff have not reappraised resident” is deemed UNSUBSTANTIATED at this time.

Additionally, the complaint alleges that the facility is charging resident for services not rendered, referring to charges for transfer assistance, escort to meals and activities, and additional laundry services. As indicated above, from 12/23/2020 – 02/17/2021, the facility was under the direct guidance from Ventura County Public Health to isolate COVID positive residents and for residents to remain in their rooms for safety. Interviews revealed that the facility was not charging separate line items for transfer assistance and escorts. The facility charged for an overall level of care, which did include these items, but also includes assistance with ADLs, such as incontinence care, medication management, assistance with grooming and hygiene tasks. All items R1 required care with determined the level of care and therefore the charge associated with R1’s care. Additionally, activities were closed during the time Public Health required, but this was only temporary during the COVID outbreak. Transfer assistance was still provided between bed and wheelchair and R1’s

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210211151422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROYAL GARDENS OF CAMARILLO	FACILITY NUMBER: 565801653
	VISIT DATE: 01/27/2023

NARRATIVE

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chair. Escort services were limited temporarily during the outbreak, but even if escort services had been removed from R1’s service plan, the level of care and charge would have remained the same based on R1’s overall care needs. Interview revealed that R1 was paying for an additional laundry service weekly and this was completed by facility housekeeping staff. This service was agreed upon with R1’s responsible party and interview revealed was being provided by the facility as scheduled. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “facility is charging resident for services not rendered” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided by email and mail.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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