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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802408
Report Date: 11/05/2021
Date Signed: 11/05/2021 07:06:11 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
10/29/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20211029151249
FACILITY NAME:REGAL CAREFACILITY NUMBER:
565802408
ADMINISTRATOR:BRODT, DONALDFACILITY TYPE:
740
ADDRESS:3316 GREENVILLE AVENUETELEPHONE:
(805) 587-2992
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 7DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Donald BrodtTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility exceeded capacity
Facility staff violated residents personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM and explained the reason for visit. Entrance interview conducted.

LPA along with Donald tour the facility inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 regulations.

It was alledged that facility exceeded capacity. Starting at 11:30 a.m., LPA interviewed Administrator Donald regarding facility census. Admin stated that they currently have six (6) resident but they have an additional resident #7 (R7) that has been staying at the facility for two (2) months. Donald added that R7 broke their hip about 4 months ago and R7's family had asked Donald if R7 can stay at the facility for 2 weeks until R7 recovers.
Continued on LIC 90990-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 5
Control Number 29-AS-20211029151249
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: REGAL CARE
FACILITY NUMBER: 565802408
VISIT DATE: 11/05/2021
NARRATIVE
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Donald continued, those 2 weeks turned into 2 months that R7 has been living here. R7 is independent but we do help with providing self administration of medication and stand by assist in the showers. R7 sleeps in a recliner in another resident room. Interview with R7 starting at 12:00 PM, revealed that R7 has been at the facility for a few months. R7 confirmed that the facility is proving stand-by assist in the showers and are helping with self administration of medications on a daily basis. At 12:10 p.m., LPA received a copy of R7's Medication Administration Record (MAR) for the month of November 2021 and Physician's Report. Interview with staff #1 (S1) at 12:17 p.m. revealed that the staff are helping R7 with medication and stand-by assist in the showers. At 12:55 p.m. LPA received a copy of R7's August 2021, September 2021 and October 2021 checks for rent payment.

Based on interviews and evidence gathered throughout the investigation, the allegation facility exceeded capacity is substantiated at this time.

It was also alleged that the facility staff violated residents personal rights. Interview with Donald at 11:30 a.m. revealed that R7 has been staying at the facility for 2 months and is incorporated in all the activities, meals and care on a daily basis. Interview with R7 at 12:00 p.m. revealed that they eat, do activities and help out other resident in need by calling out the staff. R7 also added that they have the freedom to come and go throughout the facility and have access to other part of the house besides other resident bedrooms.

Based on interviews and evidence gathered throughout the investigation, the allegation Facility staff violated residents personal rights is substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of


Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email to the admin.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20211029151249
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: REGAL CARE
FACILITY NUMBER: 565802408
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
87158(a)
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87158 Capacity (a) A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time. The capacity shall be exclusive of any members of the licensee's own family who reside at the facility... ensure the provision of adequate care and supervision for the residents.
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Admin will assist in relocation of R7 with in 24 hours. Admin will provide a photograph or statement of proof of R7's relocation to LPA via email @ angel.ascencio@dss.ca.gov
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Based on documents gathered, interviews and observations the licensee did not comly with the section cited above as the facility exceeded capacity limits of 7 out 6 residents which poses an immiedate health, safety and personal right violation to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20211029151249
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: REGAL CARE
FACILITY NUMBER: 565802408
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/19/2021
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Admin will provide training to all staff via outside agency regarding personal rights and will submit proof of training material and attendees to LPA via email at: angel.ascencio@dss.ca.gov
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Based on documents, interviews and observations the licensee did not comly with the section cited above as the licensee accepted and provided care and supevision to a 7th resident thus taking away care needs of those who have a rental agreement and care plans which poses a potential health, safety and personal right violation to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
10/29/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20211029151249

FACILITY NAME:REGAL CAREFACILITY NUMBER:
565802408
ADMINISTRATOR:BRODT, DONALDFACILITY TYPE:
740
ADDRESS:3316 GREENVILLE AVENUETELEPHONE:
(805) 587-2992
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 7DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Donald BrodtTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Resident's bedroom used as passageway to another resident bedroom
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM and explained the reason for visit. Entrance interview conducted.

It was alledged that resident's bedroom is used as a passageway to another resident bedroom. LPA Ascencio conducted interviews and reviewed facility sketch. It was revealed that the room is a shared room. The room is divided by a curtain in the middle of the room to maintain privacy between the resident's that reside in the room.

Based on observation and review of records, the allegation residents bedroom used as a passageway to another resident bedroom is deemed unsubstatiated.
Exit interview conducted. Copy of the report provided to admin via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5