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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609831
Report Date: 08/11/2021
Date Signed: 08/11/2021 02:44:47 PM

Substantiated


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
08/10/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210810132009
FACILITY NAME:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR:JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:80CENSUS: 56DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brandon JakobovichTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff failed to allow resident to have private visits while in care
Facility staff failed to ensure resident received phone calls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial visit. The LPA met with Administrators Ashley Jackson, Holly Gold, and Brandon Jakobovich and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:24 a.m., 9:50 a.m., 10:20 a.m., 11:19 a.m., and 11:39 a.m. The LPA interviewed Resident #1 (R1) at 10:59 a.m., and interviewed a family member of R1 at 12:59 p.m. In addition, the LPA reviewed files at 9:20 a.m. and toured R1’s room at 11:15 a.m.

Regarding the allegation: Facility staff failed to ensure resident received phone calls while in care
It was alleged that on numerous occasions, excuses are made to ensure that R1 does not receive phone calls from one specific caller. Staff interviews confirmed that since moving into this facility, R1 has become very involved in facility activities and is oftentimes preoccupied when calls come in. Staff claimed that they have asked R1 if they wanted to speak to the caller on the phone, and R1 will decline to speak to the caller.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 5
Control Number 29-AS-20210810132009
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 OAKS INN
FACILITY NUMBER: 567609831
VISIT DATE: 08/11/2021
NARRATIVE
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R1's interview revealed that at the time of the interview, R1 felt comfortable speaking with the caller in question, and stated that they, "spoke to them when they felt like it". Interviews revealed that staff were adamant in asking R1 if they wanted to speak to the caller and although this information was relayed to the caller, the caller continued to persist in speaking with R1. Records review and interviews confirmed that due to the excessive amount of calls, staff would inform the caller that the resident is preoccupied or unavailable, even without asking R1 if they would like to speak to the caller. This incident took place as recent as 8/8/2021. Based on the information obtained, there is sufficient evidence to support the claim that staff failed to ensure R1 received phone calls. This allegation is deemed Substantiated at this time.

Regarding the allegation: Facility staff failed to allow resident to have private visits while in care
It was alleged that R1 was not allowed to have private visitation. Interviews conducted revealed that R1 received a visit from a specific visitor on 8/2/2021 and 8/3/2021. Interviews revealed that on 8/2/2021, R1 had a visitor and the visitor was escorted to R1’s room. However, R1’s Power of Attorney (POA) was contacted, and R1’s private visit was interrupted and ultimately stopped. It is alleged that the situation became volatile and it was in the best interest of R1's wellbeing to stop the visit altogether. On 8/3/2021, R1 had another visit from the same visitor whom arrived on 8/2/2021. R1 was able to have their visit in R1’s room, yet staff stood outside the door while the visit was taking place. It is alleged that staff overheard the visitor asking to take a picture of R1, to which staff interrupted the visit and stated that they did not have permission to take a photo of R1. Thereafter, the visit ended. An interview with R1 revealed that at the time of the interview, R1 felt comfortable seeing the visitor and did not communicate concern in seeing the vistor. Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to ensure that R1 had private visits while in care. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210810132009
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 OAKS INN
FACILITY NUMBER: 567609831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/16/2021
Section Cited
CCR
87468.1(a)(14)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have reasonable access to telephones, to both make and receive confidential calls.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Meet with the resident and the POA to discuss best ways to best meet R1's needs. Submit Statement of Understanding, communicating how R1's personal rights will be maintained.
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility did not ensure that R1 received their calls, which poses a potential personal rights risk to residents in care.
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Request Denied
Type B
08/16/2021
Section Cited
CCR
87468.2(a)(2)
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87468.2(a)(2) Additional Personal Rights of Residents in Privately Operated Facilities. To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations ...
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Meet with the resident and the POA to discuss best ways to best meet R1's needs. Submit Statement of Understanding, communicating how R1's personal rights will be maintained.
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility did not ensure that R1 received private visits, which poses a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/10/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210810132009

FACILITY NAME:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR:JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:80CENSUS: 56DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Brandon JakobovichTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff failed to ensure that resident received mail while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial visit. The LPA met with Administrators Ashley Jackson, Holly Gold, and Brandon Jakobovich and explained the reason for the visit.
During today’s visit, the LPA interviewed staff at 9:24 a.m., 9:50 a.m., 10:20 a.m., 11:19 a.m., and 11:39 a.m. The LPA interviewed Resident #1 (R1) at 10:59 a.m., and interviewed a family member of R1 at 12:59 p.m. In addition, the LPA reviewed files at 9:20 a.m. and toured R1’s room at 11:15 a.m.

Regarding the allegation: Facility staff failed to ensure that resident received mail while in care
It was alleged that the facility staff are withholding mail from R1. Interviews with staff and a family member of R1 confirmed that R1 has received mail at the facility. R1’s family member confirmed observing the mail in R1’s possession in their room at the facility. Staff interviews revealed that when mail comes to residents, the mail is sorted according to the room number and is promptly delivered to the resident. Staff denied claims that they have failed to ensure that R1, or any resident, received their mail. R1’s family member also denied claims that they removed R1’s mail from R1’s possession.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210810132009
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 OAKS INN
FACILITY NUMBER: 567609831
VISIT DATE: 08/11/2021
NARRATIVE
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 When asked if they have received mail at the facility, R1 responded with ‘No.’ However, that does not mean that R1 has not received mail at this time. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to ensure that R1 received mail. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5