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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610363
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:40:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/13/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240913135055
FACILITY NAME:AAA ROYAL SENIOR LIVING FACILITYFACILITY NUMBER:
197610363
ADMINISTRATOR:KRISTINA ADMAYANFACILITY TYPE:
740
ADDRESS:6214 BECKFORD AVETELEPHONE:
(818) 609-0117
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kristina Admayan, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure care needs for resident are being met.
INVESTIGATION FINDINGS:
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At 11:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with Vanissa Campbell, Staff #1 (S1), who granted access to the facility. The Administrator, Kristina Admayan, arrived shortly after and LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 11:50 AM, LPA requested resident and staff roster. At 11:55 AM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician Report, Appraisal Needs and Services Plan, and etc., relevant to the investigation. At approximately 12:00 PM, LPA conducted a physical plant tour. Between 12:10 PM – 1:00 PM, LPA conducted an interview with the Administrator, one (1) staff and four (4) out of five (5) residents who were able to communicate. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 2
Control Number 31-AS-20240913135055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AAA ROYAL SENIOR LIVING FACILITY
FACILITY NUMBER: 197610363
VISIT DATE: 09/17/2024
NARRATIVE
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Staff do not ensure care needs for resident are being met:
In regards to the allegation, it was reported that the staff did not provide any care to Resident #1 (R1) and R1 was neglected. To investigation this allegation, LPA conducted interviews with the Administrator and one (1) staff, and both denied the allegation. LPA was informed that on 09/06/2024, the staff observed that R1’s feet were swollen and immediately notified the Administrator and the physician. Moreover, the physician visited R1 at the facility and ordered laboratory work for R1. Interview with the Administrator revealed that R1’s condition drastically changed on 09/09/2024, and the Administrator called 911. Upon the arrival of Paramedics, it was recommended that R1 needs to be hospitalized; however, R1 refused 911 services. On 09/10/2024, due to R1’s condition being worsened the Administrator called 911 again and R1 was taken to the hospital. Furthermore, LPA conducted an interview with the Physician who confirmed the statement provided by the Administrator and a staff. Interviews with four (4) out of five (5) residents who were able to communicate also expressed no concerns regarding the above allegation. Based on the information obtained, there was insufficient evidence to prove that staff are not providing any care to ensuring that residents' care needs are being met. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2