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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800347
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:22:01 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200828143044
FACILITY NAME:ROYAL CARE HOMEFACILITY NUMBER:
425800347
ADMINISTRATOR:LEILANIE ACOSTA VEAFACILITY TYPE:
740
ADDRESS:338 EAST CRESTON DRIVETELEPHONE:
(805) 925-9441
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 4DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Leilanie Acosta VeaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Due to lack of supervision, resident sexually assaulted another resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Leilanie Acosta Vea and explained the reason for the visit.

On 08/28/2020, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) was sexually abused by fellow Resident #2 (R2). The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Robert Kujawa.

On 08/31/2020, from 12:46 p.m. to 1:30 p.m., LPA Diaz conducted the initial complaint visit with Administrator, Leilanie Acosta Vea. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint visit was conducted by telephonic video. LPA Diaz conducted a physical plant tour and requested copies of pertinent documents relevant to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 2
Control Number 29-AS-20200828143044
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: ROYAL CARE HOME
FACILITY NUMBER: 425800347
VISIT DATE: 11/16/2021
NARRATIVE
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Investigator Kujawa conducted interviews with staff and residents on 07/10/2020 at approximately 1:26 p.m. and 1:32 p.m.; on 07/15/2020 at approximately 1:40 p.m.; on 07/22/2020 at approximately 11:33 a.m.; and on 11/16/2020 at approximately 1:15 p.m. Several attempts were made to contact R1’s family member.

On 10/02/2020, Investigator Kujawa obtained a copy of the medical records for R1. The following is a summary of information reviewed: On 08/26/2020, during a Veterans Affairs (VA) Clinic tele-health visit, R1 reported sexual abuse from R2 assaulting R1 every night using chloroform. R1 reported informing a family member and the owner of the facility. R1 stated the owner of the facility dismissed the claims stating they were lies. R1’s family member was contacted and reported that R1 has a degenerative brain disorder which is getting worse. R1’s family member also reported R1 has a history of Paranoid Schizophrenia, currently not in mental health treatment and if R1 does not take Risperidone, R1 has delusions and gets confused. The medical notes reviewed indicated that R1 was overdue for a mental health evaluation and declined the consult referral. The VA medical notes also indicated R1 declined a forensic sexual assault exam on 08/26/2020. R1’s diagnoses with the VA clinic includes a diagnosis of Post-Traumatic Stress Disorder 100%. Discharge papers reviewed from Marion Regional Medical Center dated 03/29/2019 states numerous diagnoses including Paranoid Schizophrenia and Anxiety.

The medical records and interviews revealed that R1 has mental health issues and delusions. Interviews conducted with facility care staff and residents found that R1 was provided proper care and there were no signs of abuse or neglect. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2