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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607361
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:06:24 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220321162147
FACILITY NAME:ROYAL PALMSFACILITY NUMBER:
197607361
ADMINISTRATOR:NATALIE MALLONFACILITY TYPE:
740
ADDRESS:20548 GERMAIN STREETTELEPHONE:
(818) 772-7153
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 6DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:John MallonTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff is verbally and or physically abusive to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the administrator, John Mallon, and explained the reason for the visit.

It was alleged that Staff #1 (S1) physically and verbally abused Resident #1 (R1). To investigate the allegation, on 03/23/2022, LPA Gary Tan requested documents and interviewed staff and the Administrator between 12:30 PM to 2:30 PM. On 05/23/2023, LPA Duguma conducted a physical plant tour at 10:00 AM and interviewed residents and additional staff between 11:30 AM – 1:30 PM. During interviews with staff, S1 denied physically or verbally abusing R1 or other residents. Staff #2 (S2) revealed that S1 has never physically, or verbally abused residents. S2 also stated that R1 was very abusive to S1 and that R1 would hit, scratch and bite S1.

(CONT. on LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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 2
Control Number 31-AS-20220321162147
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYAL PALMS
FACILITY NUMBER: 197607361
VISIT DATE: 05/23/2023
NARRATIVE
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During the physical plant tour, LPA Duguma observed that residents were clean, well-groomed and did not show any signs of physical abuse such as scratches, cuts, or bruises.

Out of (six) (06) residents, LPA was able to interview only two (02). Four (04) out of (6) residents were unable to respond to LPA questions. Information revealed by residents agreed with the information provided by the staff. LPA Duguma was unable to interview R1 as they were deceased.

A review of the Departments internal files shows that there are no Incident Reports involving S1 in any physical or verbal abuse with any residents. R1’s Centrally Stored Medications and Destruction Records also shows that R1 was taking medications known to cause increased risk of bleeding and bruises that develop without known cause and grow in size.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

No immediate health and safety hazard noted during this visit,

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2