567609831-11-18-2024-29-AS-KHEN-DBERFG-20241127115909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609831
Report Date: 11/18/2024
Date Signed: 11/18/2024 05:17:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/15/2024 and conducted by Evaluator Angela Barutyan

COMPLAINT CONTROL NUMBER: 29-AS-20241115145747

FACILITY NAME:	ROYAL OAKS INN		FACILITY NUMBER:	567609831
ADMINISTRATOR:	JAKOBOVICH, BRANDON		FACILITY TYPE:	740
ADDRESS:	45 ERBES RD		TELEPHONE:	(805) 495-4657
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	80	CENSUS: 49	DATE:	11/18/2024
		UNANNOUNCED	TIME BEGAN:	11:03 AM
MET WITH:	Brandon Jakobovich		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Physical abuse by staff led resident sustaining a large bruise.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 10:08AM. LPA met with Administrator Holly Gold and Licensee Brandon Jakobovich. Entrance interview conducted.

During today's visit, LPA interviewed eight (8) staff, two (2) residents, conducted a health and safety check at 11:50AM, and reviewed and obtained copies of pertinent documents.

At approximately 12:05PM, LPA discussed allegations with Licensee and Administrator.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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 3

Control Number 29-AS-20241115145747

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROYAL OAKS INN	FACILITY NUMBER: 567609831
	VISIT DATE: 11/18/2024

NARRATIVE

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It was alleged that physical abuse by staff led resident to sustain a large bruise. Interviews with Licensee, Administrator, Staff #1 (S1), and Staff #2 (S2) agreed that on 10/08/2024, Resident #1 (R1) asked S1 to leave their wheelchair by the bed before S1 left R1’s room, but S1 did not feel it would be safe since it would prompt R1 to attempt to transfer from the bed alone and risk a fall. R1 got agitated and swung the phone pull cord at S1, which then led to S1 grabbing R1’s hand to remove the pull cord. S2 stated they were nearby and heard R1 yelling “stop hitting me.” S2 stated they immediately went to R1’s room and observed R1 holding the pull cord and S1 trying to remove the pull cord before R1 could hurt S1. S2 stated that S1 was not hitting R1, but R1 claimed that S1 slapped their hand. S1 denied the claim and told S2 they were trying to remove the pull cord. S2 stated they told S1 to leave the wheelchair by R1’s bed and to leave the room so R1 could calm down. S2 stated they did not observe marks on R1 or S1 and that there have been no other incidents with R1. The complainant alleged that a large bruise was observed on R1’s right arm that was different colors, indicating the bruise could be older. The complainant stated that R1 has a condition which gives R1 an unsteady gait and has caused multiple falls, and that it is possible the bruise is from a previous fall. However, the complainant stated that R1 stated multiple times that facility staff hit R1. According to the complainant, R1 did not initially state that S1 hit R1 and R1 denies every hitting S1. LPA interviewed R1 who stated that they “feel safe” but there was an incident two weeks ago where staff “punched” R1. R1 stated they do not remember the staff member, what they look like, or what events led up to the incident. R1 was unable to provide additional details to LPA. R1 stated they were told that the staff member would be kept away from them. The complainant, S1, Licensee, Administrator, and S2 also confirmed that S1 will not tend to the resident and is covering a different section of the facility. The complainant, R1, Licensee, and Administrator, all confirmed that R1 stated they do not want S1 to lose their job.

Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20241115145747

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROYAL OAKS INN	FACILITY NUMBER: 567609831
	VISIT DATE: 11/18/2024

NARRATIVE

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The Licensee conducted an investigation and had undetermined findings due to S1 and R1 having different accounts of the incident. Family of R1 stated they felt the incident was handled in a satisfactory way. Record review of R1’s medical records indicate that R1 is prescribed a daily 81 mg dose of Aspirin, a blood thinner medication that could cause easy bruising. A physician’s report dated 08/06/2024 and appraisals dated 08/08/2024 indicate that R1 has an abnormal gait, mild cognitive impairment, requires a walker and wheelchair, is able to self-transfer out of bed or chair, and is a high fall risk. Licensee and Administrator stated that although the physician’s report documents that R1 is able to self-transfer, that determination might not be accurate because the physician’s report was completed at a skilled nursing facility and not by R1’s primary care provider. S2 stated that S1 does not like to leave wheelchairs by residents’ beds so that residents are more inclined to call staff for transfer assistance rather than attempting to transfer alone. S2 stated that this has prevented many falls, but that they told S1 to leave the wheelchair by R1’s bed anyway due to R1’s request. Staff #3 (S3), Staff #4 (S4), and the Administrator confirmed that R1 had 1-2 falls when R1 first moved into the facility, but that there have not been falls within the last month. S3 stated that R1 is alert sometimes, but also has moments of forgetfulness where R1 cannot recall events, repeats phrases, and exhibits dementia symptoms. During staff interviews, S1, S2, and Staff #5 (S5) who showered R1 on 11/16/2024 and 11/13/2024, stated they did not observe any marks or bruises on R1. Licensee and Administrator stated they were not aware of any marks or bruising on R1. However, at 3:48PM, LPA observed a 2-inch purple bruise on R1’s upper right arm with larger yellow and green hues surrounding the purple mark. LPA asked R1 about the bruise, R1 initially stated they were punched by a staff member but then stated that they do not remember where the bruise came from. LPA reviewed a body check conducted by Guardian Angel Home Health on 10/22/2024, that documented that R1 did not have any bruising. Based on interviews, record review, and observation, the Department does not have sufficient evidence to corroborate the allegation. 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 “Physical abuse by staff led resident sustaining a large bruise” is deemed UNSUBSTANTIATED at this time.

No deficiencies issued. Exit interview conducted. A copy of the report provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC9099 (FAS) - (06/04)

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