565801851-11-23-2022-29-AS-JAPL-CMXSSU-20230110130827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801851
Report Date: 11/22/2022
Date Signed: 11/23/2022 12:33:56 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, 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 CARE		FACILITY NUMBER:	565801851
ADMINISTRATOR:	KAREN ROSALES		FACILITY TYPE:	740
ADDRESS:	1106 ROYAL AVENUE		TELEPHONE:	(805) 210-2757
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Karina Antig		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff caused resident to fall
Staff physically restrained resident
Staff prevented resident from leaving facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations to amend the complaint findings for three of the allegations. 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.

(continued 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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: 11/22/2022

NARRATIVE

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Regarding the allegations that staff caused a resident (R1) to fall, staff physically restrained resident, and staff prevented resident from leaving the facility, the complainant’s concern was that inappropriate behavior by staff, which included physically restraining R1 in an effort to prevent them from exiting the facility, caused R1 to fall.

During the interviews conducted on 7/21/2022, S1 stated that on 7/7/2022, R1 attempted to elope from the facility through the garage as R1 wanted additional cigarettes and to return home. S1 stated they prevented R1 from leaving the facility by blocking R1, but S1 insisted to the LPA they did not put their hands on R1. S1 stated they were holding a plate of food at the time and R1 slapped the plate of food out of S1’s hand. S1 stated that the action of hitting the plate caused R1 to lose their balance and fall back into some boxes in the garage. During LPA’s interview with R1, they gave substantively the same statement.

However, during the LPA’s interviews with witnesses and review of police records, it was found that R1 and S1 gave different statements to the police. On 7/7/2022, S1 told the police that they grabbed R1’s wrists to prevent R1 from leaving the facility. While holding R1’s wrists, S1 walked R1 backward into the garage but R1 lost their balance and fell. R1’s statement to the police on 7/7/2022 indicated S1 grabbed R1 by the shoulder and pushed r1 down. The police did not find any evidence of assault, but they did indicate to the administrator the staff should have a hands-off approach to addressing R1’s elopement attempts.

Although the above noted allegations were found unsubstantiated during the initial complaint visit on 7/21/2022, after further review of documents and additional witness interviews, the above noted allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Today's report and appeal rights were discussed and emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/02/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	Administrator will conduct training with staff regarding personal rights and not restraining residents and provide evidence of this training to CCL by 12/02/2022.
	8 9 10 11 12 13 14	Based on observation, interview and record review, the licensee did not comply with the section cited above, as R1 was physically restrained by S1, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/02/2022 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house	1 2 3 4 5 6 7	Administrator will conduct training with staff regarding personal rights and not stopping residents from leaving the facility (ok to follow) and provide evidence of this training to CCL by 12/02/2022.
	8 9 10 11 12 13 14	rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. Based on observation, interview and record review, the licensee did not comply with the section cited above, as R1 was physically restrained	8 9 10 11 12 13 14	from leaving facility, which poses a porential health and safety risk to residents in care.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

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