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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801851
Report Date: 07/21/2022
Date Signed: 11/23/2022 12:36:15 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, 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
07/18/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220718164215
FACILITY NAME:ROYAL OAKS HOME CAREFACILITY NUMBER:
565801851
ADMINISTRATOR:KAREN ROSALESFACILITY TYPE:
740
ADDRESS:1106 ROYAL AVENUETELEPHONE:
(805) 210-2757
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Karina AntigTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff accused resident of theft
Staff is not giving resident medications on time
Staff is not maintaining a medication log
Staff caused resident to scratch arm
Staff elbowed resident in abdomen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to amend the report regarding the above noted allegations. Please refer to the LIC 9099-A for the previously unsubstantiated allegations which after re-evaluation were changed to a substantiated finding. The LPA met with co-administrator Karina Antig and explained the reason for the visit. This amended report is to address findings issued on 7/21/2022.
On 7/21/2022, LPA Camara interviewed staff 1 (S1) at 12:30 p.m., the administrator at 12:50 p.m., and resident 1 (R1) at 2:30 p.m. LPA was unable to interview other residents due to their cognitive issues. On 10/20/2022, LPA Camara interviewed witness 1 (W1) at 3:20 p.m. and witness 2 (W2) at 3:47 pm. On 11/15/2022, LPA Camara interviewed witness 3 (W3) at 3:03 p.m.
Regarding the allegation staff accused a resident of theft, specifically stealing another resident’s bowl of oatmeal, LPA interviewed staff and R1. It was found that S1 had left the dining room to bring out another resident for breakfast and when S1 returned they discovered that R1 had eaten the other resident’s oatmeal. S1 informed R1 that if they wanted more food they can just ask, but R1 was offended and called 9-1-1 for
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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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Control Number 29-AS-20220718164215
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 OAKS HOME CARE
FACILITY NUMBER: 565801851
VISIT DATE: 07/21/2022
NARRATIVE
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the police. Based on police records and witness statements, R1 told the police S1 accused R1 of stealing another resident’s oatmeal. However, when LPA interviewed R1, R1 stated there was a misunderstanding about the theft accusation on 7/5/2022 and it was in fact another resident who accused R1 of theft. Therefore, the allegation staff accused resident (R1) of theft, is found as UNSUBSTANTIATED.

Regarding the allegation staff is not giving R1 medications on time, LPA conducted interviews with staff and R1. While the police were at the facility on 7/5/2022, R1 told the police that staff were not giving their medications on time. LPA reviewed medication records which indicated R1 was being given medications as prescribed. During R1’s interview with the LPA on 7/21/2022, they stated they have been receiving medications on time, as prescribed. Therefore, due to conflicts in statements by R1, the allegation that staff are not giving the resident medication on time is UNSUBSTANTIATED.

Regarding the allegation staff are not maintaining a medication log, LPA conducted interviews with staff, R1, administrator and a witness. LPA also reviewed the medication logs as well as physician orders for R1. The medications logs were complete, and it appeared R1 was receiving medications as prescribed. The witness had stated the morning medications had not been logged during their visit on 7/5/2022. Staff indicated they administer medications with breakfast and write in the log later in the morning or early afternoon. During LPA’s visit the medication logs appeared to be properly maintained. Therefore, based on this investigation, the allegation that staff are not maintaining a medication log, the finding is UNSUBSTANTIATED.



Regarding the allegations staff caused resident to scratch arm and staff elbowed resident in abdomen during staff intervention to prevent R1 from eloping from the facility, LPA conducted interviews with staff, administrator, R1 and a witness. Staff and administrator stated R1 was frustrated about not receiving enough cigarettes and had increased anxiety causing R1 to want to leave the facility. R1's conservator had instructed administrator to scale back on the amount of cigarettes R1 smoked daily. R1 had reported to the police on 7/7/2022 that S1 caused a scratch on their arm and elbowed them in the abdomen. However, witness interviews and a review of police records did not indicate any evidence that R1 was scratched on their arm or elbowed in the abdomen by S1. When LPA interviewed R1 on 7/21/22, R1 was not sure how their arm was scratched and denied being elbowed in the abdomen. R1 confirmed the reason for getting upset and trying to leave the facility boiled down to wanting more cigarettes and their desire to go back home. R1 admitted to being very difficult with staff. R1 stated they slapped a plate of food out of S1’s hand on 7/7/2022 while trying to elope. R1 had no complaints about staff and said they feel safe with all the staff and the administrator at the facility. R1 has agreed with the administrator to call the administrator first, before calling 9-1-1, whenever R1 feels frustrated in the future.

Based on the information obtained from interviews and records, the allegation staff caused resident to scratch arm and staff elbowed resident in abdomen are deemed UNSUBSTANTIATED at this time. Exit interview conducted and report emailed to administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
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