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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607361
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:13:38 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
08/24/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230824085032
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: 5DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Fernando Afable, Staff TIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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At 12:15pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to deliver final report. LPA met with Staff #1 (S1), who granted access to the facility. LPA contacted the Administrator and explained the reason for the visit. Administrator was unable to come and designated S1 to sign for today's report.

During the initial visit conducted by LPA Panushkina on 08/30/23, interviews and record review were made. LPA requested resident and staff roster and copies of pertinent information which include, but not limited to Admission Agreement, Physician’s report, Appraisal Needs and Services Plan, Resident Appraisal and Staff training, etc., relevant to the investigation. In addition, between 10:00am – 12:00pm, LPA interviewed the Administrator, two (2) staff members and five (5) out of six (6) residents. The Administrator was informed that additional visit will follow to render final findings.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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-20230824085032
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: 09/29/2023
NARRATIVE
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During today's visit, before delivering the final report, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations.

It was alleged that R1's hearing aids gone missing and the facility did not refund/replace them. To investigate this allegation, during the initial visit LPA conducted an interview with R1 and was informed that in 2021, R1's family bought R1 a new hearing aid to replace the old one that was no longer working. According to R1, during the dinner time, R1 took the old hearing aid out and replaced it with the new one. Interview with R1 also revealed that the old hearing aid was wrapped in a tissue and left it on a dinner table. By the time R1 recalls leaving the hearing aid on a dinner table, the table was already cleaned and the trash was thrown. Interview with R1's family revealed that the incident with R1's hearing aid was just an honest mistake and not facility's s fault. Moreover, during the initial visit, LPA also interviewed the Administrator and two (2) staff and all denied the allegation and reported no staff ever takes/steals from residents. Based on inspection and interviews there is no sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

No Deficiency cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2