Inspection Reports for Studio Royale by Cogir

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.

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.

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.

An unannounced case management visit was conducted due to a complaint investigation regarding staff association with the facility.

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.

The visit was complaint-related and substantiated by the observation that Staff #1 (Neyba Padilla) was not associated with the facility during the investigation.

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.

The investigation found all allegations unsubstantiated based on record reviews, observations, and interviews with residents and staff. No deficiencies were cited during the visit.

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.

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.

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.

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.

The inspection was an unannounced annual required visit to evaluate compliance with licensing requirements for the facility.

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.

An unannounced complaint investigation visit was conducted to address the allegation that staff do not treat residents with respect.

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.

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.

The visit was an unannounced complaint investigation to determine if staff addressed a resident's change in medical condition.

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.

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.

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.

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.

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.

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.

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.

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.

The department conducted a complaint investigation following an allegation that staff did not prevent a resident from choking another resident.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff mismanaged residents' medications.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not ensure resident's bandages were being changed.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not following infection control protocols.

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.

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.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations regarding staff care and facility conditions at Studio Royale.

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.

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.

The visit was a 10-day complaint investigation subsequent visit initiated due to a complaint, to assess compliance and safety conditions at the facility.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted to investigate the allegation that facility staff failed to maintain a comfortable temperature at the facility.

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.

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.

The inspection visit was conducted as a case management inspection in association with complaint 11-AS-20230726113120.

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.

The visit was triggered by complaint 11-AS-20230726113120. The findings substantiated violations related to failure to report and failure to provide safe accommodations.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation was conducted due to an allegation that facility bathrooms were in disrepair.

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.

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.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures.

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.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not dispense medications as prescribed.

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.

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.

The inspection was an unannounced complaint investigation initiated due to an allegation that staff disclosed resident's personal information to other residents.

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.

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.

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.

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.

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.

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.

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.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.

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.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2021-11-04 regarding reporting requirements at the facility.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted due to an allegation that a resident suffered a stroke from not receiving medications as prescribed.

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.

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.

An unannounced complaint investigation visit was conducted regarding an allegation that staff did not administer medication as prescribed to a resident.

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.

The complaint alleged that staff did not administer medication as prescribed to a resident. The allegation was unsubstantiated after investigation.

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.

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.

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.

The inspection was an unannounced complaint investigation triggered by an allegation that residents' medications were not being provided as prescribed.

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.

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.

report_40_198601566_inx39_2025-03-27.pdf