Inspection Reports for Studio Royale by Cogir
3975 Overland Ave, Culver City, CA 90232, United States, CA, 90232
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. However, the facility had some substantiated deficiencies primarily related to medication management, resident care documentation, and maintaining safe, comfortable accommodations. Notably, a January 21, 2025 report cited deficiencies for issuing an unlawful eviction notice and failing to report incidents properly, while earlier investigations in 2023 and 2024 identified issues with medication record-keeping, pest control, and facility maintenance. The most recent report from October 28, 2025 had no deficiencies and involved an unsubstantiated complaint of physical assault. Overall, the facility appears to have improved over time, with recent inspections showing fewer issues compared to earlier years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
An unannounced Case Management/Incident visit was conducted following an Unusual Incident Report received regarding a resident's allegation of physical assault by two facility staff members.
Complaint Details
The complaint involved a resident alleging physical assault by two female African American facility staff members. The resident reported defending themselves by throwing punches. The staff members stated they only work day shifts and denied any assault. No physical injuries were observed by the facility executive director, who also contacted the police.
Findings
The Licensing Program Analyst did not observe any deficiencies during the visit, and no citations were issued. The resident reported being physically assaulted but could not recall full details, and the staff members denied the allegations.
Report Facts
Capacity: 175
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Boles | Executive Director | Met with Licensing Program Analyst during the visit and involved in assessment of the incident |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the unannounced Case Management/Incident visit |
| Ernest D. Lewis | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 1
Date: Aug 8, 2025
Visit Reason
An unannounced case management visit was conducted due to a complaint investigation regarding staff association with the facility.
Complaint Details
The visit was complaint-related and substantiated by the observation that Staff #1 (Neyba Padilla) was not associated with the facility during the investigation.
Findings
The Licensing Program Analyst observed that Staff Neyba Padilla was not associated with the facility at the time of the unannounced complaint investigation, posing an immediate health, safety, or personal rights risk to persons in care. Civil penalties were assessed and a deficiency was cited under California Code of Regulation Title 22, Division 6, Chapter 8.
Deficiencies (1)
Staff Neyba Padilla was not associated to the facility at the time of unannounced complaint investigation, posing an immediate health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 175
Census: 89
Plan of Correction Due Date: Aug 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Neyba Padilla | Staff not associated with the facility at time of complaint investigation | |
| William Boles | Executive Director | Met during exit interview |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 175
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-05-19 regarding multiple allegations about staff conduct and care at the facility.
Complaint Details
The complaint included allegations that staff did not dispense medication as prescribed, did not assist residents timely, interfered with resident visits, and failed to provide requested records timely. All allegations were found unsubstantiated after investigation.
Findings
The investigation found all allegations unsubstantiated based on record reviews, observations, and interviews with residents and staff. No deficiencies were cited during the visit.
Report Facts
Estimated Days of Completion: 90
Residents interviewed: 9
Staff interviewed: 7
Deficiencies cited: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Tamera Gant | Health and Wellness Director | Facility staff member met during the investigation and exit interview |
| Ernest D. Lewis | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 175
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-03-21 alleging that staff do not treat residents with respect.
Complaint Details
The complaint alleged that a resident dropped a knife on the floor and a staff member picked it up and threw it back on the resident's table. Interviews with the facility administrator, six staff members, and six residents all denied the allegation or witnessing such behavior. Observations during meal service showed respectful treatment of residents. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to support the allegation that staff treated residents disrespectfully. Interviews with staff and residents, observations, and record reviews indicated that residents were treated with dignity and respect. The allegation was determined to be unsubstantiated.
Report Facts
Number of staff interviewed: 6
Number of residents interviewed: 6
Number of residents denying allegation: 5
Number of staff denying allegation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Lee | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Ernest D. Lewis | Administrator | Facility administrator interviewed regarding the allegation |
Inspection Report
Annual Inspection
Census: 94
Capacity: 175
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
The inspection was an unannounced annual required visit to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be adequately maintained, sanitary, and appropriately furnished with no deficiencies cited during the inspection. All safety measures, including fire extinguishers and fire drills, were in place and operational.
Report Facts
Licensed capacity: 175
Current census: 94
Bedridden capacity: 5
Non-ambulatory capacity: 74
Hospice capacity: 5
Inspection start time: 800
Inspection end time: 1620
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamera Grant | Health and Wellness Director | Met with Licensing Program Analyst during inspection |
| William Boles Jr. | Executive Director | Met with Licensing Program Analyst during inspection |
| Yolanda Rosser | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to address the allegation that staff do not treat residents with respect.
Complaint Details
The complaint alleged that a resident dropped her knife on the floor and a staff member picked it up and threw it back on her table. Interviews with the Facility Administrator, six staff members, and six residents all denied the allegation or witnessing such behavior. Observations during meal service showed residents were treated respectfully.
Findings
The investigation included interviews with staff and residents, observations, and review of training and certification records. No evidence was found to support the allegation, and the complaint was determined to be unsubstantiated. No deficiencies were cited.
Report Facts
Staff interviewed: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Lee | Licensing Program Analyst | Conducted the complaint investigation |
| Ernest D. Lewis | Administrator | Facility Administrator who denied the allegation |
| Tamara Gant | Wellness Director | Greeted Licensing Program Analyst and received report copy |
| Bill Boles | Executive Director | Spoke with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 3
Date: Jan 21, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to investigate the allegation that staff did not provide a lawful eviction notice to a resident in care.
Complaint Details
The complaint alleged that staff did not provide a lawful eviction notice to a resident in care. The investigation found that the eviction notice issued to Resident #1 was invalid and did not comply with Title 22 regulations. The allegation was substantiated based on interviews, observations, and record reviews.
Findings
The investigation substantiated the allegation that the facility issued an unlawful eviction notice to Resident #1, failing to comply with California State Department of Social Services Community Care Licensing Title 22 Regulations. The eviction notice was incomplete and lacked critical information and required reporting to the licensing agency.
Deficiencies (3)
Failed to issue a valid eviction notice in compliance with Title 22 Regulations, lacking critical information and referral services.
Failed to report incidents involving Resident #1's health and safety welfare as required by Title 22 regulations.
Administrator failed to adhere to Title 22 regulations, resulting in multiple citations.
Report Facts
Capacity: 175
Census: 92
Plan of Correction Due Date: Feb 4, 2025
Number of Deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Boles Jr. | Executive Director | Met with during the investigation and named in the exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
The visit was an unannounced complaint investigation to determine if staff addressed a resident's change in medical condition.
Complaint Details
The complaint alleged that staff did not address a resident's change in medical condition. Interviews with staff and residents, review of records, and observations showed that care services were updated and staff did address changes. The allegation was unsubstantiated.
Findings
The investigation found no sufficient evidence to support the allegation that staff did not address a resident's change in medical condition. The allegation was unsubstantiated and no deficiencies were observed during the visit.
Report Facts
Facility capacity: 175
Census: 92
Staff interviewed: 8
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
| Tamera Gant | Health and Wellness Director | Met with Licensing Program Analyst during investigation and signed report |
| Ernest D. Lewis | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 175
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate the allegation that the facility failed to ensure staff were adequately trained in emergency evacuation.
Complaint Details
The complaint alleged that on 11/7/24, facility staff were uninformed on how to handle emergency evacuation during a fire alarm, with no staff available to assist non-ambulatory residents on the second floor. Interviews with staff and residents, and review of emergency plans and training records, did not corroborate the allegation. The fire alarm was a false alarm, and staff were found to be adequately trained and equipped.
Findings
The investigation included interviews with staff and residents, a tour of the facility, and review of relevant records. The Department found no sufficient evidence to support the allegation, concluding the complaint was unsubstantiated.
Report Facts
Facility capacity: 175
Staff interviewed: 3
Residents interviewed: 8
Emergency Evacuated Chairs observed: 3
Fire Drill Reports reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamera Gant | Wellness Director | Met with during investigation and participated in exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 175
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff did not provide a resident with a call button, did not ensure the resident was hydrated, and did not provide a responsible party with a refund.
Complaint Details
The complaint investigation addressed three allegations: 1) Staff did not provide resident with a call button; 2) Staff did not ensure that resident was hydrated; 3) Staff did not provide responsible party with a refund. All allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Findings
Based on record reviews, interviews, and observations, the Department found no evidence to support the allegations. All allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Refund amount alleged: 932
Complaint received date: Complaint received on 11/08/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamera Gant | Health and Wellness Director | Met with during investigation and provided information regarding allegations |
| Ernest D. Lewis | Administrator | Facility administrator named in report header |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on report |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation |
| Executive Director | Interviewed regarding refund allegation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
The department conducted a complaint investigation following an allegation that staff did not prevent a resident from choking another resident.
Complaint Details
The allegation was that staff did not prevent a resident from choking another resident. Interviews with five staff members and six residents, as well as record reviews, indicated the incident never happened. The facility took steps to address concerns, including removing one resident from the shared room. The allegation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with staff and residents, review of records, and a facility tour. The allegation was found to be unsubstantiated due to insufficient evidence to prove the incident occurred. No deficiencies were cited.
Report Facts
Capacity: 175
Census: 90
Staff interviewed: 5
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamera Gant | Health Wellness Nurse Director | Met with during investigation and provided information about the allegation and facility response |
| Ernest D. Lewis | Administrator | Named as facility administrator |
| Antonine Richard | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 175
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-01 regarding allegations that the facility prohibited residents from receiving private care of their own choosing and failed to report an incident involving a resident as necessary.
Complaint Details
The complaint involved two allegations: 1) the facility prohibited residents from receiving private care of their own choosing, and 2) the facility did not report an incident involving a resident as necessary. Both allegations were found to be unsubstantiated after investigation.
Findings
The investigation found both allegations to be unsubstantiated based on interviews with staff, residents, and review of records. Residents reported they were allowed to choose their own private care, and staff confirmed incidents were reported as required. No evidence supported the claims of prohibited private care or failure to report incidents.
Report Facts
Capacity: 175
Census: 94
Residents interviewed: 9
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Tamera Gant | Health and Wellness Director | Interviewed regarding allegations and facility practices |
| Ernest D. Lewis | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-10-18 regarding billing and eviction allegations at Studio Royale facility.
Complaint Details
The complaint included three allegations: 1) Resident's invoice statement is not correct; 2) Staff would not give an itemized invoice to resident; 3) Staff threatened resident with eviction. All allegations were found unsubstantiated after review of records, interviews with residents and staff, and document examination.
Findings
The investigation found no preponderance of evidence to substantiate the allegations regarding incorrect resident invoice statements, refusal to provide itemized invoices, and staff threatening eviction. No deficiencies were observed or cited during the visit.
Report Facts
Capacity: 175
Census: 86
Charges: 72
Charges: 156
Resident interviews: 11
Staff interviews: 8
Eviction notice review period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| EJ Lewis | Executive Director | Participated in exit interview and was provided a copy of the report |
| Tamera Grant | Health and Wellness Director | Met with Licensing Program Analyst during the visit |
| Ernest D. Lewis | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 175
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with regulations. No deficiencies were cited during the inspection. Food storage, fire safety equipment, medication room, and laundry facilities were inspected and found satisfactory.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 5
Fire drills frequency: 1
Food delivery frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest D. Lewis | Administrator / Executive Director | Met with Licensing Program Analyst during inspection and received report copy |
| Sparkle Day | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 6
Date: Mar 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-14 regarding multiple allegations about staff not safeguarding residents' personal items, not addressing resident abusive behavior, not preventing hoarding, and not keeping the facility free of roaches.
Complaint Details
The complaint alleged that staff did not safeguard residents' personal items due to theft by another resident, did not address abusive behavior by a resident, did not prevent hoarding by a resident, and did not keep the facility free of roaches. The investigation included interviews with staff and residents and review of records. All allegations were substantiated.
Findings
All four allegations were substantiated based on interviews with staff and residents and records reviewed. Deficiencies were cited related to safeguarding residents' personal property, addressing abusive behavior, preventing hoarding, and maintaining a pest-free environment. Plans of correction were discussed with the facility.
Deficiencies (6)
Failure to safeguard residents' personal items, resulting in theft by another resident.
Failure to address resident's abusive behavior towards other residents.
Failure to prevent resident from hoarding various items, creating a potential health risk.
Failure to keep the facility free of roaches, despite bi-monthly pest control services.
Failure to provide safe, healthful, and comfortable accommodations due to hoarding behavior.
Failure to maintain the facility in a clean, safe, sanitary, and good repair condition.
Report Facts
Capacity: 175
Census: 86
Deficiency count: 6
Fine amount: 100
Plan of Correction Due Date: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Guadalupe Delgado | Leave Concierge | Met with the investigator during exit interview |
| Ernesto Lewis | Administrator | Facility administrator who greeted the investigator and responsible for plan of correction |
| Terri Weitzman | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff mismanaged residents' medications.
Complaint Details
The complaint was substantiated. The allegation was that facility staff mismanaged residents' medications, including missed medications and unfilled prescriptions. The investigation included interviews, record reviews, and a facility tour. The facility did not provide requested manual medication logs and failed to notify the department of pharmacy switch issues.
Findings
The investigation found that residents had missed several days of medications and that the facility failed to maintain accurate medication records, particularly for resident 3. The facility had a pharmacy change and used a manual medication log which was not provided to the investigator. The complaint was substantiated.
Deficiencies (1)
Facility staff failed to make accurate records for prescribed medications for resident 3, violating medication record-keeping requirements.
Report Facts
Capacity: 175
Census: 86
Staff interviewed: 6
Residents interviewed: 9
Plan of Correction due date: Mar 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Executive Director | Facility administrator interviewed and involved in medication management discussion |
| Felisa Shirley | Licensing Program Analyst | Investigator conducting the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 175
Deficiencies: 0
Date: Jan 6, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff do not respond to resident requests for assistance in a timely manner.
Complaint Details
The complaint alleged that staff did not assist resident #1 for over an hour after activating the call button following a fall. The complainant did not provide specific details such as date, time, or staff involved. Interviews with residents and staff, and review of monitoring logs showed timely assistance and monitoring. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to support the allegation that staff failed to respond timely to resident requests. Interviews with residents and staff, review of monitoring logs, and observation showed residents were assisted within minutes and monitored every two hours. The allegation was unsubstantiated and no deficiencies were identified.
Report Facts
Staff interviewed: 7
Residents interviewed: 10
Monitoring frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Danilo Aguilan | Resident Lifestyle Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
| Ernest D. Lewis | Administrator | Facility administrator contacted by phone during the investigation. |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 175
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure resident's bandages were being changed.
Complaint Details
The complaint alleged that staff did not ensure resident's bandages were being changed. After interviews with staff members and residents, review of records, and observations, the allegation was deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found no substantiated evidence to support the allegation. Interviews with staff and residents indicated that bandages were being changed appropriately, with wound care managed by qualified professionals and home health agencies. The facility was found to be providing adequate care and supervision, and no deficiencies were cited.
Report Facts
Capacity: 175
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ernest Lewis | Administrator | Facility administrator met during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-12-15 regarding staff response times to resident calls, water temperature appropriateness, and dishwasher condition.
Complaint Details
The complaint alleged that staff did not respond to residents' calls in a timely manner, water temperature was not appropriate for residents, and the facility dishwasher was in disrepair. The investigation found these allegations to be unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and the administrator, along with record reviews and facility tours, indicated that staff generally responded to calls within 5-10 minutes, water temperatures were maintained between 105°F and 120°F, and the dishwasher was functioning properly.
Report Facts
Residents interviewed: 9
Staff interviewed: 9
Water temperature range: 105-120
Facility capacity: 175
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernesto Lewis | Executive Director | Administrator interviewed regarding complaint allegations and investigation |
| Alfonso Iniguez | Licensing Program Analyst | Investigator who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
The inspection visit was conducted to investigate complaints alleging that the licensee does not ensure faucets for personal care deliver adequate water for residents and that staff do not provide adequate food service to residents.
Complaint Details
The complaint alleged inadequate water pressure and hot water in faucets for personal care and inadequate food service temperature. The investigation included interviews with residents and staff, facility inspection, and review of records. The allegations were found unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence to support the allegations. The faucets were operational with adequate water pressure and temperature, and residents reported no issues. Food service was found to be adequate with options for residents to refuse and replace meals if unsatisfied. The allegations were determined to be unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 4
Public restrooms inspected: 4
Water temperature range: 107.4
Water temperature range: 109.9
Water pressure range: 45
Water pressure range: 80
Water shut-off duration: 1.5
Number of servers: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rhonda Madrid | Marketing Director | Met with Licensing Program Analyst during investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
| Zoila Marroquin | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 175
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not following infection control protocols.
Complaint Details
The complaint alleged that the facility was not following infection control protocols. Interviews with six staff members and six residents, as well as observations, indicated that staff were following Covid-19 protocols, including mask-wearing. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with staff and residents, observations, and record reviews. No sufficient evidence was found to substantiate the allegation that the facility was not following infection control protocols. The allegation was determined to be unsubstantiated.
Report Facts
Staff interviewed: 6
Residents interviewed: 6
Total staff: 34
Facility capacity: 175
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest D. Lewis | Administrator | Administrator who assisted with the visit and was interviewed |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rhonda Madrid | Community Relations Director | Assisted with the facility tour and investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations regarding staff care and facility conditions at Studio Royale.
Complaint Details
The complaint included allegations that staff did not address changes in resident's condition, did not ensure adequate feeding, did not keep rooms clean, left residents soiled in urine for extended periods, left mattresses on the floor, and did not keep the facility free of flies. All allegations were investigated and found unsubstantiated.
Findings
The investigation found no sufficient evidence to support any of the allegations including failure to address changes in resident condition, inadequate feeding, unclean rooms, leaving residents soiled, mattresses left on the floor, or presence of flies. The facility was found to be safe, sanitary, and compliant with care standards.
Report Facts
Residents interviewed: 10
Staff interviewed: 8
Witnesses interviewed: 2
Facility capacity: 175
Facility census: 89
Pest control service dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Danilo Aguilan | Resident Lifestyle Director | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 2
Date: Nov 2, 2023
Visit Reason
The visit was a 10-day complaint investigation subsequent visit initiated due to a complaint, to assess compliance and safety conditions at the facility.
Complaint Details
The visit was a complaint investigation subsequent visit (11-AS-20231025142545) initiated due to a complaint. The facility was found to have deficiencies related to maintenance and operation.
Findings
The Licensing Program Analyst found that several bathroom ceiling fans/vents were not working contrary to staff statements, and movable bins used for solid waste did not have tight-fitting covers or were not in good repair, resulting in citations for maintenance and operation violations.
Deficiencies (2)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure.
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Nov 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David España | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Danilo Aguilan | Resident Lifestyle Director | Met with Licensing Program Analyst during the visit and assisted with inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 175
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that facility staff do not ensure incontinent residents are cleaned properly and that staff transfer residents in a rough manner.
Complaint Details
The complaint investigation was triggered by allegations received on 2022-11-03 regarding improper cleaning of incontinent residents and rough transfer of residents. The allegations were found unsubstantiated based on interviews with staff and residents, observations, and record reviews.
Findings
After inspection, observation, interviews with staff and residents, and review of facility records, there was no sufficient information or evidence to verify the allegations. Both allegations were deemed unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Residents interviewed: 10
Staff interviewed: 5
Resident census: 91
Facility capacity: 175
Resident #1 transfer assistance requirement: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest EJ Lewis | Administrator | Met with Licensing Program Analyst during the investigation and named in the exit interview |
| David Espana | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that facility staff failed to maintain a comfortable temperature at the facility.
Complaint Details
The complaint alleged that the AC in the facility was not working for 13 days, leaking water, and that staff failed to maintain a comfortable temperature. The investigation included interviews, room temperature assessments, and inspection of multiple apartments and common areas. A new AC system was scheduled for installation in the affected apartment.
Findings
The investigation found that although the AC system in one resident's apartment was not working and was being serviced with portable units, the temperature in the facility was within a comfortable range and other residents reported no concerns. The allegation was determined to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Days AC not working: 13
Room temperature range: 76
Room temperature range: 78
Room temperature range: 75
Room temperature range: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
| EJ Lewis | Executive Director | Interviewed during investigation and participated in exit interview |
| Kelly Metz | Vice President of Operations | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 175
Deficiencies: 2
Date: Jul 27, 2023
Visit Reason
The inspection visit was conducted as a case management inspection in association with complaint 11-AS-20230726113120.
Complaint Details
The visit was triggered by complaint 11-AS-20230726113120. The findings substantiated violations related to failure to report and failure to provide safe accommodations.
Findings
The Department observed that the air conditioning system in resident #1's room was in disrepair and found that the licensee failed to report this issue to Community Care Licensing. Additionally, the licensee failed to provide safe and comfortable accommodations to residents #1 and #2, resulting in citations for violations of Title 22 regulations.
Deficiencies (2)
Failed to report the disrepair AC system for resident #1's apartment to Community Care Licensing, posing a potential health and safety risk.
Failed to provide safe and comfortable accommodations to residents #1 and #2, posing a potential health and safety risk.
Report Facts
Census: 89
Total Capacity: 175
Deficiencies cited: 2
Plan of Correction Due Date: Aug 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the case management inspection visit and authored the report |
| EJ Lewis | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Kelly Metz | Vice President of Operations | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 175
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility was not meeting the needs of the resident in care.
Complaint Details
The complaint alleged that the facility was not meeting the needs of Resident #1, specifically regarding a non-urgent 911 transport to the hospital. The investigation included interviews with residents, staff, a responsible party, and review of records. The allegation was unsubstantiated.
Findings
The investigation found that Resident #1 was transported to the hospital by EMS after symptoms were observed, but the hospital determined the resident did not require medical attention. Interviews with residents and staff indicated the facility was meeting residents' daily needs. The allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 175
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wilfredo Guerrero | Health Wellness Director | Met with during the investigation and named in the report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
A Case Management visit was initiated on 06/02/2023 to investigate a complaint regarding the facility's lack of a current Executive Director on file and failure to provide a Designation of Facility Responsibility LIC 308 to Community Care Licensing for review.
Complaint Details
The visit was complaint-related, investigating the absence of a current Executive Director and failure to provide required documentation. The deficiency was substantiated and a citation issued.
Findings
The facility was found not to have an authorized Executive Director on file and was not in compliance with PIN 21-24 CCLD. A citation was issued for failure to meet the requirement of having a qualified and currently certified administrator, posing a potential health and safety risk to residents.
Deficiencies (1)
Facility did not have an authorized administrator on file with Community Care Licensing Division, posing a potential health and safety risk to residents.
Report Facts
Capacity: 175
Census: 92
Deficiency count: 1
Plan of Correction Due Date: Jun 9, 2023
Fine amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wilfred Guerrero | Resident Services Director | Met with Licensing Program Analysts and provided information about the facility's lack of Executive Director |
| Terri Weitzman | Administrator | Named as the active administrator on record but not in compliance with licensing requirements |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection and signed the report |
| Janae Hammond | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 175
Deficiencies: 2
Date: Jun 1, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to investigate allegations that staff did not notify the responsible party of a resident's change in condition and did not seek medical attention for the resident in a timely manner.
Complaint Details
The complaint was substantiated. Allegations included failure to notify the responsible party of a resident's change in condition and failure to seek timely medical attention for the resident. The resident exhibited aggressive behavior and was diagnosed with a manic episode after a tele-health appointment initiated by a witness.
Findings
The investigation substantiated both allegations, finding that staff failed to notify the responsible party of the resident's behavioral changes and did not seek timely medical attention for the resident, who was later diagnosed with a manic episode. Deficiencies under Title 22 regulations were cited.
Deficiencies (2)
Failed to ensure that changes to residents are documented and brought to the attention of the resident's physician and responsible person.
Failed to ensure that staff have the knowledge necessary to recognize early signs of illness and the need for professional help.
Report Facts
Estimated Days of Completion: 90
Census: 91
Total Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wilfred Guerrero | Resident Services Director | Named in relation to findings and plan of correction development |
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 1
Date: May 30, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility bathrooms were in disrepair.
Complaint Details
The complaint alleged that facility bathrooms were in disrepair. Interviews with staff and residents confirmed that residents' bathrooms were fully operational, but public restrooms had temporary issues with toilets being out of service for four to five days due to plumbing problems caused by tree roots. The facility is actively addressing these issues with a plumber. The allegation was substantiated.
Findings
The investigation found that the public restrooms on the first floor were temporarily out of order with two toilets non-operational, while the residents' individual bathrooms were fully operational and in good condition. The allegation was substantiated based on observations, interviews, and records reviewed.
Deficiencies (1)
The licensee needs to repair two of the toilets in the public restroom on the first floor. The public restroom toilets should be in operational condition and in good repair at all times for the safety and well-being of residents, employees, and visitors.
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Jun 7, 2023
Census: 92
Total Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Willie Guerrero | Health Wellness Director | Met with Licensing Program Analyst and provided supporting documents |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 91
Capacity: 175
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures.
Findings
The facility was found to be in compliance with regulations, including clean and operational bathrooms, adequate food supplies, proper medication management, and effective infection control practices. No deficiencies were cited during this inspection.
Report Facts
Licensed capacity: 175
Current census: 91
Number of resident rooms: 92
Water temperature range: 110.8 to 117.1
Food supply duration: 4
Food supply duration: 7
Fire extinguisher last serviced: Sep 22, 2022
Fire alarm and sprinkler last serviced: Feb 16, 2023
Last emergency drill date: Feb 8, 2023
Elevator last inspected: Oct 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the inspection and authored the report |
| Chanel Lee | Resident Care Coordinator | Met with Licensing Program Analyst during the inspection |
| Terri Weitzman | Administrator | Facility administrator named in the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 91
Capacity: 175
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures.
Findings
The facility was inspected for compliance with infection control and physical plant standards. Resident rooms, linens, and common areas were found to be adequately maintained with no hazards or obstructions noted.
Report Facts
Licensed capacity: 175
Current census: 91
Resident rooms: 35
Resident rooms: 57
Elevator last inspected: Oct 27, 2022
Hospice approved beds: 5
Bedridden residents allowed: 5
Non-ambulatory residents allowed: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the inspection visit |
| Chanel Lee | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 175
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not dispense medications as prescribed.
Complaint Details
The allegation was that staff did not dispense medications as prescribed. Interviews revealed that 3 out of 4 staff disagreed with the allegation, 1 staff member was unaware, and 1 out of 10 residents agreed while 8 disagreed and 1 was unsure. The investigation concluded there was not enough evidence to prove the alleged violation occurred.
Findings
The investigation included interviews with staff and residents and a facility tour. There was insufficient evidence to substantiate the allegation, and the complaint was deemed unsubstantiated. No deficiencies were cited.
Report Facts
Census: 98
Total Capacity: 175
Staff interviewed: 4
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar | Licensing Program Analyst | Conducted the complaint investigation visit |
| Chanel Lee | Care Coordinator Medication | Interviewed during investigation and provided information on medication dispensing |
| Terri Weitzman | Administrator | Facility administrator named in the report |
| Ulysses Coronel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 175
Deficiencies: 0
Date: Oct 26, 2022
Visit Reason
The inspection was an unannounced complaint investigation initiated due to an allegation that staff disclosed resident's personal information to other residents.
Complaint Details
The allegation was that staff disclosed resident's personal information to other residents. Interviews with 10 residents and 6 staff found no concerns or evidence supporting the allegation. A 30-day pay or quit notice served to a resident was documented and handled confidentially. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with residents and staff, review of documents, and a plant inspection. No evidence was found to support the allegation, and no deficiencies were identified. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 6
30-day pay or quit notice date: Sep 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Eldridge | Interim Executive Director | Participated in investigation and exit interview |
| Chanel Lee | Care Coordinator Medications | Participated in investigation |
| Kelly Metz | Vice President | Joined investigation by phone |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 175
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident was left on the floor after falling until the next morning and that the facility does not provide a safe environment for residents.
Complaint Details
The complaint was unsubstantiated based on interviews, observations, and records reviewed. Although the incident occurred, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents confirmed the facility provides 24-hour care with awake staff conducting room checks throughout the night. The resident who fell was found on the floor the next morning, but there was no evidence she was left unattended for hours. No deficiencies were cited.
Report Facts
Capacity: 175
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terri Weitzman | Executive Director | Met with Licensing Program Analyst and provided statements regarding the investigation |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Maria Garcia | Caregiver | Interviewed regarding the resident fall incident |
| Chanel Lee | Medication Supervisor | Assessed resident after fall and reported incident |
Inspection Report
Census: 93
Capacity: 175
Deficiencies: 0
Date: May 11, 2022
Visit Reason
The visit was an unannounced Case Management Visit to amend a prior Complaint Investigation Report dated 12/15/2021 related to staff testing positive for COVID-19 and to request supporting documents.
Findings
The facility was found clear of COVID-19 infection with proper COVID-19 screening and sanitizing measures observed. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the unannounced Case Management Visit and explained the purpose of the visit. |
| Terri Weitzman | Executive Director | Met with Licensing Program Analyst during the visit and was involved in the COVID-19 risk assessment. |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 97
Capacity: 175
Deficiencies: 0
Date: Apr 5, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary and appropriately furnished with no deficiencies cited. Infection control practices, including screening protocols and PPE supply, were observed to be adequate. Fire and disaster drills were up to date, and all mandated inspection control posters were posted.
Report Facts
Licensed capacity: 175
Census: 97
Fire drill date: Mar 20, 2022
Disaster drill date: Mar 20, 2022
Water temperature range (F): 105.1-116.6
Hospice beds: 5
Bedridden beds: 5
Non-ambulatory beds: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terri Weitzman | Executive Director | Met with Licensing Program Analyst during inspection and received report copy |
| Don Senaha | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 175
Deficiencies: 0
Date: Dec 15, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2021-11-04 regarding reporting requirements at the facility.
Complaint Details
The complaint involved reporting requirements related to COVID-19 positive cases. The investigation concluded the allegation was unsubstantiated as the facility self-reported all positive cases timely and adhered to all regulatory guidelines.
Findings
The investigation found that the facility staff and residents are fully vaccinated and boosted, COVID-19 positive cases are reported timely to all appropriate parties, and the facility follows Title 22 Regulations and infection control protocols. The allegation was unsubstantiated as staff and residents denied the complaint and documentation supported compliance.
Report Facts
Capacity: 175
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Terri Weitzman | Executive Director | Met with Licensing Program Analyst and provided documentation during the investigation |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 175
Deficiencies: 1
Date: Nov 9, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2021-11-04 regarding pest control issues and medication administration at the facility.
Complaint Details
The complaint investigation was substantiated for the allegation of staff not keeping resident rooms free from pests, with evidence including pest control invoices and observations. The medication administration allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated the allegation that staff did not keep resident rooms free from pests, citing evidence of roach infestations and flies in certain areas, though the issue was self-reported and corrected prior to the visit. The allegation that a resident was not administered medication as prescribed was found unsubstantiated based on interviews, observations, and medication records.
Deficiencies (1)
Failure to maintain the facility clean, safe, sanitary and in good repair, specifically related to pest control issues including roach infestations and flies in the kitchen, dining room, and bathroom.
Report Facts
Capacity: 175
Census: 90
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Terri Weitzman | Executive Director | Facility administrator met during the investigation and involved in the exit interview |
| Angela J Kendrick | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 175
Deficiencies: 1
Date: Oct 6, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that a resident suffered a stroke from not receiving medications as prescribed.
Complaint Details
The complaint was substantiated. The allegation was that a resident suffered a stroke from not receiving medications as prescribed. Interviews with staff and residents, review of medication administration records, and observations confirmed the medication error. The facility self-reported the incident to the resident's family and appropriate agencies within required timeframes.
Findings
The investigation found that the facility's medication technicians failed to administer Resident 1's medications correctly, specifically missing doses of Pradaxa from 12/13/2020 to 12/15/2020, which posed an immediate health and safety risk. The allegation was substantiated based on interviews, observations, and record reviews.
Deficiencies (1)
Medication records were observed. Resident 1 did not receive Pradaxa medications as prescribed by her physician on 12/13/2020-12/15/2020, posing an immediate health and safety risk to residents in care.
Report Facts
Deficiencies cited: 1
Census: 87
Total Capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terri Weitzman | Executive Director | Met with Licensing Program Analyst and self-reported the medication incident |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 175
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not administer medication as prescribed to a resident.
Complaint Details
The complaint alleged that staff did not administer medication as prescribed to a resident. The allegation was unsubstantiated after investigation.
Findings
The investigation included review of medication administration records and interviews with residents and staff. It was found that the facility ran out of required eye drops on one day, but there was no preponderance of evidence to prove the alleged violation occurred. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 175
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jade Jordan | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Jones | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Terri Weitzman | Facility Administrator | Met with investigators and provided information during the investigation |
| Michael Cava | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 175
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/07/2021 regarding medication administration timeliness and staff intimidation of a resident.
Complaint Details
The complaint involved two allegations: 1) Resident did not receive her medication on time, and 2) Staff intimidated the resident. The investigation was unsubstantiated for both allegations due to insufficient evidence.
Findings
The investigation found that a resident did not receive her morning medication on time due to a pharmacy packaging error, but the medication was provided within the same hour. The allegation of staff intimidation was unsubstantiated as there was no preponderance of evidence to prove the claim.
Report Facts
Capacity: 175
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terri Weitzman | Executive Director | Met with during investigation and discussed allegations |
| Jennifer Jones | Licensing Program Analyst | Conducted the complaint investigation |
| Jade Jordan | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Cava | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 175
Deficiencies: 3
Date: Oct 27, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that residents' medications were not being provided as prescribed.
Complaint Details
The complaint investigation was substantiated. The allegation was that residents' medications were not being provided as prescribed. Evidence showed R1 refused medication multiple times over several months, and the facility failed to report or address this properly.
Findings
The investigation substantiated the allegation that medications were not provided as prescribed, specifically noting that one resident (R1) refused a specific medication at bedtime for 25 consecutive days without proper reporting or intervention. The facility failed to notify the physician and responsible party timely and did not submit required incident reports, posing potential health and safety risks.
Deficiencies (3)
Failed to develop a plan with R1's physician when R1 did not take medication as ordered for 25 consecutive days.
Failed to ensure staff informed R1’s physician and responsible person about R1 refusing prescribed medications.
Failed to submit written reports to the licensing agency and responsible person within seven days of R1 refusing medication for 25 consecutive days.
Report Facts
Refusal duration: 25
Resident census: 92
Facility capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ulysses Coronel | Licensing Program Analyst | Conducted the complaint investigation |
| Terri Weitzman | Administrator | Facility administrator involved in interviews and exit discussion |
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