Inspection Reports for
Victor Royale, LLC

The facility was toured and inspected for compliance with health, safety, and licensing standards. No citations were issued, and resident and staff records were complete and updated. The facility was found to be clean, well-maintained, and properly stocked with food and medical supplies.

The complaint alleged that staff did not ensure the facility was in good repair, specifically citing a missing towel rack and a needed grab bar in a bathroom. The complaint was investigated and found unsubstantiated.

The investigation found the towel rack brackets were present but the towel bar was missing, and a grab bar was present and usable near the toilet. Residents reported no issues with the missing towel rack or grab bar, and no maintenance concerns were raised with staff. The allegation was deemed unsubstantiated with no immediate health or safety hazards observed.

The complaint alleged that staff did not ensure a menu was written up at least a week in advance. After interviews, observations, and records review, there was insufficient evidence to support the allegation. The complaint was unsubstantiated.

The investigation found that weekly menus were prepared and posted in advance as required, with a temporary handwritten menu used during a technical issue. The complaint was deemed unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated. Allegations included inadequate supervision leading to a resident leaving unsupervised and insufficient staffing to meet resident needs. Both allegations were found unsubstantiated based on interviews, record reviews, and observations.

The investigation found insufficient evidence to substantiate the allegations. The resident was able to leave unassisted and did not require supervision. Staffing levels were adequate according to staff interviews and schedule reviews. No immediate health and safety hazards were noted.

The complaint alleged that staff did not ensure the facility’s water temperature was properly regulated, specifically at the back patio faucet. The allegation was unsubstantiated after investigation.

The investigation found that water temperature at the back patio faucet was 117 degrees Fahrenheit, which is within acceptable limits for that sink. Interviews with residents and staff revealed no complaints about water temperature. The allegation was unsubstantiated due to insufficient evidence of a violation.

The complaint investigation was unsubstantiated based on interviews with five residents and staff, and review of medication records and facility reports.

The investigation found no evidence to substantiate the allegations. Interviews with residents and staff, as well as record reviews, indicated that the resident was given medication as prescribed and no rough handling by staff was observed or reported.

The complaint alleged that staff left Resident #1 in soiled diapers for an extended period and did not meet toileting needs. The allegation was unsubstantiated based on observations, interviews, and record review.

The investigation found that all residents were clean and well-groomed with no malodor. Staff and residents reported that incontinent residents are checked and changed every two hours. The allegation was unsubstantiated due to insufficient evidence.

The complaint involved allegations of physical abuse, lack of dignity and respect by staff, and a resident wandering away from the facility. After investigation, all allegations were found to be unsubstantiated due to lack of evidence.

The investigation found no sufficient evidence to substantiate any of the allegations. Observations, interviews with staff and residents, and record reviews indicated no physical abuse or harassment, staff treated residents with dignity and respect, and the resident was able to leave the facility unassisted. The allegations remain unsubstantiated.

The facility was found to be clean, well-maintained, and compliant with safety and health standards. No health or safety hazards were noted during the visit.

The complaint alleged that staff did not ensure the menu was available for review by residents. The allegation was unsubstantiated based on interviews, observations, and records review.

The investigation found no health or safety issues and determined that the allegation was unsubstantiated. Staff communicated menu information to residents during a temporary printer outage, and the menu was posted within 48 hours.

The complaint involved allegations of stolen personal belongings and inadequate pest control. The allegations were deemed unsubstantiated after interviews with residents and staff, review of documents including pest control reports, and physical inspection of the facility.

The investigation found insufficient evidence to substantiate the allegations of stolen personal belongings and improper pest control. Interviews, document reviews, and physical inspections revealed no confirmed theft or pest infestation issues at the time of the visit.

The complaint alleged that the facility license was not posted in a prominent location accessible to public view. The allegation was found to be unsubstantiated based on observation and staff interviews.

The investigation found that the facility license was posted inside the assistant administrator's office with clear windows and was also posted inside the Licensee's office until recently. During the visit, a copy of the license was posted near the entrance. The allegation was unsubstantiated with no health and safety issues noted.

The complaint alleged that the signal system in resident R1's room was not consistently functional. After investigation, including testing the signal system alerts and interviewing staff and the resident, there was insufficient evidence to confirm the allegation. The complaint was deemed unsubstantiated.

The investigation included a physical plant tour, staff and resident interviews, and review of maintenance records. The allegation was found to be unsubstantiated as the signal system was observed to function properly and maintenance checks showed no dysfunction.

The complaint alleged that a staff or resident sent Resident #1 inappropriate pictures. Interviews with staff and residents did not confirm the allegation. The allegation was unsubstantiated.

The investigation included interviews with staff and residents. There was insufficient evidence to verify the allegation, and it was determined to be unsubstantiated. No health and safety hazards were noted during the visit.

The complaint alleged that Staff #1 took Resident #1's card and withdrew money without permission. Interviews and document reviews showed the resident had the card and did not suspect fraud. The allegation was unsubstantiated.

The investigation found that the resident had a positive ledger balance and did not suspect staff of financial abuse. The resident stated they withdrew money themselves and kept cash in their room. The allegation was unsubstantiated due to insufficient evidence.

The complaint alleged that staff were not providing comfortable temperatures for residents, the porch lacked hand railings, and a doorhandle was in disrepair causing injury. All allegations were investigated and found unsubstantiated.

All allegations were found to be unsubstantiated based on interviews with residents and staff, and physical observations by the Licensing Program Analyst. No citations were issued.

The complaint was unsubstantiated based on interviews, record reviews, and observations. The resident fall allegation lacked sufficient evidence, and the floor condition allegation was not supported as a new floor was being installed.

The investigation found insufficient evidence to substantiate the allegations. The resident's fall was unwitnessed and no injuries were found, and the floor was being replaced with no disrepair observed at the time of inspection.

The complaint was unsubstantiated based on staff interviews and facility record reviews. The resident was found to be incontinent but adequately cared for, and allegations of neglect were not supported.

Interviews and record reviews found that the resident is incontinent but able to communicate needs and is provided with timely diaper changes and toileting assistance. There was insufficient evidence to support the allegations, and no health or safety hazards were noted.

The complaint was unsubstantiated based on interviews and records review. Allegations included inadequate supervision leading to a resident leaving unsupervised and insufficient staffing to meet resident needs. Both allegations were found unsubstantiated.

The investigation found insufficient evidence to support the allegations. Staff interviews and record reviews confirmed that the facility is not locked but residents can come and go as they please, and that staffing levels are sufficient with at least two caregivers per shift.

The complaint alleged that staff did not seek medical attention after a resident fell and suffered significant injuries including a broken nose, dislocated jaw, and spine injuries. The investigation included interviews with residents and staff, review of medical and incident records, and found no substantiation of the allegation.

The investigation found no evidence that staff failed to seek medical attention for the resident. Medical records and interviews indicated the resident frequently visited the emergency room for fibromyalgia-related pain and there was no indication of untreated injuries as alleged. The complaint was unsubstantiated.

No health and safety issues were observed during the physical plant tour. Staff personnel and training records were obtained.

The complaint involved three allegations: staff physically abused a resident, staff did not treat a resident with dignity and respect, and due to lack of supervision a resident wandered away. All allegations were found to be unsubstantiated based on interviews and records review.

All allegations were investigated through staff interviews and records review. There was no substantiated evidence of physical abuse, harassment, or lack of supervision. The resident has a history of self-harming behavior and psychiatric hospitalizations. The facility is not locked and residents are free to come and go. The wandering incident was reported to police and the resident returned safely.

The complaint alleged that staff did not ensure the menu was made available for review by residents. The allegation was found to be unsubstantiated based on observations, interviews, and records review.

The investigation found that the allegation was unsubstantiated. The menu was eventually printed and posted after internet and printer ink issues were resolved, and menus were available for review during the visit.

The facility was found to be in compliance with health and safety regulations, including proper resident accommodations, operational safety equipment, and adequate staff and resident file documentation. No citations or health and safety violations were noted during the inspection.

The complaint alleged that staff were not assisting residents with getting COVID vaccinations. The allegation was found to be unsubstantiated based on interviews and records review.

The investigation found that all residents had been vaccinated for COVID, confirmed by staff interviews, resident interviews, and facility records. The allegation was unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to notify resident of positive COVID test, failure to provide medical records, and failure to quarantine resident. Investigation found insufficient evidence to verify these allegations.

The investigation found that the resident was not COVID positive but had inconclusive test results and was notified to stay in their room as a precaution. The facility does not store medical records; the resident was advised to request them from their doctor. Staff did instruct the resident to quarantine out of precaution. All allegations were unsubstantiated based on interviews and records review.

The complaint investigation was unsubstantiated for all allegations after interviews with staff, residents, and observations. Allegations included staff failing to prevent injury, yelling, medication refusal, temperature discomfort, and inappropriate speech. No sufficient evidence was found to support any allegation.

All allegations including staff not preventing resident injury, yelling at residents, medication administration issues, uncomfortable facility temperature, and inappropriate staff speech were investigated and found to be unsubstantiated based on interviews and observations.

The complaint alleged that staff did not administer Resident #1's medication as prescribed. The investigation found no missed doses in the last three months and confirmed the medication was taken with a slight delay. The allegation was unsubstantiated.

The investigation found that the resident did receive the prescribed medication with only a minor delay of about an hour, which was within an acceptable timeframe. The allegation was deemed unsubstantiated based on interviews and record reviews.

The investigation determined that Staff #1 and Staff #2 violated personal rights regulations. The licensee was informed and provided with copies of the exclusion orders and relevant government code.

The complaint investigation was unsubstantiated. Allegations included poor facility maintenance and restricted telephone access. Interviews with staff and residents, and observations, did not support these claims. No deficiencies were cited.

The investigation found no evidence to support the allegations. The facility was generally maintained in good repair with operable utilities and equipment. Residents had access to telephones that could be used comfortably and freely. Therefore, both allegations were deemed unsubstantiated.

The complaint alleged that the licensee does not maintain the facility in good repair. The allegation was unsubstantiated due to lack of evidence. Interviews with staff and residents, and observations of the facility showed ongoing maintenance and operable systems.

The investigation included interviews with staff and residents, observation of resident rooms, bathrooms, common areas, and facility systems. The investigation did not find evidence to support the allegation, and the facility was found to be maintained in good repair with no deficiencies cited.

The complaint alleged that staff allowed residents to access a hazardous burnt cottage area. The investigation included a physical plant tour, interviews with staff and residents, and document review. The allegation was deemed unsubstantiated based on evidence and interviews.

The investigation found that the burnt cottage area was secured with a fence and a coded cable rope, accessible only by staff. Interviews and observations determined that residents did not have unauthorized access, and the allegation was unsubstantiated.

The complaint involved allegations that a resident caused injury to another due to lack of supervision, access to hazardous items, theft of personal belongings, and restricted bathroom access. After interviews and document review, there was no preponderance of evidence to prove the allegations, resulting in an unsubstantiated finding.

The investigation found insufficient evidence to substantiate the allegations of lack of supervision causing injury, access to hazardous items, failure to safeguard personal belongings, and restricted bathroom access. The allegations were determined to be unsubstantiated.

The complaint alleged that a resident caused injury to another resident due to staff's lack of supervision. Interviews with staff and residents, as well as observations, did not substantiate the allegation.

The investigation found that staff were supervising dining and common areas as required. Interviews with staff and residents indicated supervision was generally present. The allegation was unsubstantiated due to insufficient evidence.

The complaint investigation was unsubstantiated. Allegations included that the licensee did not ensure facility doors were kept in good repair and allowed residents to access a hazardous area. Interviews with residents and staff, as well as facility observations, did not confirm these allegations.

The investigation found no preponderance of evidence to substantiate the allegations. Facility doors were not observed to be in disrepair, and the hazardous vacant cottage was blocked off and not accessible to residents.

The complaint involved allegations of lack of supervision causing injury, resident access to hazardous items, failure to safeguard personal belongings, and restricted bathroom access. The investigation included interviews with staff and residents and review of incident reports. The allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents provided conflicting statements, and documentation did not support the claims. The allegations were therefore deemed unsubstantiated.

The complaint investigation addressed allegations including a resident sustaining a bruise without timely medical care, staff locking fire exit doors, improper hot water temperature, staff harassment of a resident, failure to uphold resident admission agreements, and malfunctioning auditory signal systems. After interviews, observations, and record reviews, all allegations were found unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate any of the allegations, including resident injury without timely medical care, locked fire exit doors, improper water temperature, staff harassment, failure to uphold admission agreements, and malfunctioning auditory signal systems. All tested systems and interviews supported that the facility was compliant with regulations.

The complaint alleged that staff do not follow COVID-19 protocol. The investigation was unannounced and included interviews and a physical plant tour. The allegation was found to be unsubstantiated.

The investigation found that staff were wearing masks, COVID-19 posters were displayed, PPE supplies were adequate, hand sanitizers and soap were available, and residents reported receiving hygiene supplies regularly. The allegation was deemed unsubstantiated.

No deficiencies were observed during the visit. The fire incident on 11/02/22 caused relocation of six residents and made five rooms inaccessible until repairs are completed.

The complaint alleged that a resident was locked out of the facility by staff for five minutes. Interviews with staff and residents did not corroborate the allegation. The licensing analyst observed the door lock was difficult to operate. The allegation was unsubstantiated.

The investigation found no preponderance of evidence to prove the alleged violation occurred. Interviews with staff and residents did not confirm the allegation, and the door lock was found difficult to operate. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that staff were not providing privacy for residents when using the phone. Interviews with 5 residents and 5 staff members indicated no privacy issues. The allegation was unsubstantiated.

Interviews with residents and staff, as well as a tour of the facility, showed that privacy for phone use is provided in multiple locations. The allegation was found to be unsubstantiated due to lack of evidence.

The complaint alleged that facility staff did not clean up feces on the floor, specifically in the cottages where a resident was reportedly smearing feces. The allegation was unsubstantiated due to lack of evidence.

The investigation found the facility to be clean and sanitary with no evidence to substantiate the allegation. Staff and residents interviewed denied seeing feces on the floor. The allegation was determined to be unsubstantiated.

The complaint involved allegations that staff did not prevent a resident from making inappropriate comments to another resident and did not ensure a resident was provided a seat during mealtime. The allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents revealed conflicting accounts, and no deficiencies were cited during the visit.

Complaint #28-AS-20220628163253 was investigated. Residents and staff denied any abuse or neglect. No deficiencies were found.

No deficiencies were observed during the visit. Residents and staff reported no incidents of staff hitting or pushing residents or leaving residents alone during showers or diaper changes.

The complaint alleged that the facility did not properly reappraise the resident. After review of documentation and interviews, the allegation was found to be unsubstantiated.

The investigation found that Resident #1 is ambulatory with reduced mobility due to severe right-hip arthritis and is awaiting surgery. There was insufficient evidence to substantiate the allegation that the facility failed to properly reappraise the resident, resulting in an unsubstantiated finding.

The complaint alleged that the resident council was not allowed to meet without a staff person present. The investigation found no preponderance of evidence to prove the alleged violation; therefore, the allegation was unsubstantiated.

The investigation found that residents are allowed to meet without staff present if requested, and staff usually attend resident council meetings to take notes but do not always stay for the entire meeting. The allegation of neglect related to resident council meetings was found to be unsubstantiated.

The complaint alleged staff failed to prevent a resident from AWOL’ing and admitted residents needing a higher level of care. The investigation found that residents are allowed to leave unassisted per physician's report and facility policy, and that admission procedures include evaluations to ensure appropriate care levels. The allegations were unsubstantiated.

Based on interviews, observations, and record reviews, there was insufficient evidence to prove or disprove the allegations, resulting in the complaint being unsubstantiated.

The complaint alleged staff were not assisting residents with medical appointments, specifically that residents had not received a second COVID booster. The investigation found residents receive assistance and the facility is coordinating with public health for booster appointments. The allegation was unsubstantiated.

The investigation found that 6 of 6 residents confirmed staff assist with medical appointments and COVID vaccinations. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff not making phones available frequently, inadequate first aid, failure to intervene in bullying, and non-adherence to the admission agreement. Interviews with residents and staff, document reviews, and facility tours did not support the allegations.

The investigation found no preponderance of evidence to substantiate any of the allegations. Telephones were accessible to residents, first aid kits were stocked and staff were trained, staff intervened in bullying when aware, and the admission agreement was followed with no health or safety issues observed.

The complaint involved allegations that staff did not keep a resident's bathroom clean and sanitary and that staff retaliated against a resident for complaining. The investigation was unsubstantiated due to lack of evidence. It was found that a resident physically prevented staff from cleaning, and the smeared feces was accidentally caused by a roommate.

The investigation found no preponderance of evidence to substantiate the allegations. The smeared feces in the bathroom was cleaned after a resident went on an outing, and staff were physically prevented from cleaning by a resident. Staff denied retaliating against residents, and observations showed the bathroom was clean.

The complaint alleged residents were not allowed to participate in their appraisal needs and services plan. The investigation was unsubstantiated due to lack of preponderance of evidence.

Interviews and document reviews revealed mixed resident responses about participation in care planning, with some residents unable to recall or stating they were not involved. Staff reported reviewing appraisal needs and care plans with residents as needed. The investigation found insufficient evidence to substantiate the allegations.

The complaint investigation was unsubstantiated. Allegations included refusal to comply with a resident's physician report and inappropriate staff communication. Interviews with staff, residents, and the administrator did not corroborate the allegations.

The investigation found no preponderance of evidence to substantiate the allegations. The facility did not comply with the resident's physician report issue was discussed but no violation was confirmed. Staff were found not to have spoken inappropriately to residents based on interviews and observations.

The complaint investigation was triggered by allegations including inappropriate staff handling of residents, locking a resident in the patio, failure to intervene in resident conflicts, not safeguarding table settings, and interfering with resident phone calls. All allegations were found unsubstantiated based on interviews and evidence gathered during the investigation.

The investigation found all allegations unsubstantiated due to lack of sufficient evidence. Interviews with residents, staff, and the administrator did not confirm any violations related to staff handling residents inappropriately, locking residents in the patio, failure to intervene in resident conflicts, safeguarding dining utensils, or interfering with resident phone calls.

The complaint alleged that a resident was not provided with a 30 day notice to change rooms. The investigation included interviews with residents and staff, and review of documentation. The allegation was found unsubstantiated.

The investigation found that although some residents and staff had varying knowledge about the room change notice process, the resident in question was given multiple notices regarding the room change due to physical health changes. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that a resident was not allowed telephone calls. The allegation was unsubstantiated after investigation.

The investigation found that 2 out of 5 residents had access to the facility's telephone and received calls, 2 residents had their own cellphones, and 1 resident was unaware of phone availability. Staff confirmed residents are allowed to make and receive calls at all times. Phone equipment was observed to be in working condition. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated as there was not enough evidence to prove the alleged violations regarding food service adequacy and dish sanitization.

The investigation found that most residents reported receiving adequate food and clean dishes. Staff confirmed sufficient food supply and proper dish sanitization procedures. There was insufficient evidence to substantiate the allegations, which were therefore deemed unsubstantiated.

The complaint alleged that a resident did not receive proper room change notice. The allegation was unsubstantiated after investigation, which included interviews with staff and residents, review of resident records, and observations.

The investigation found that the resident was initially given a one-week notice for room relocation, which was later extended to 30 days at the resident's request. The resident's physical condition had declined, justifying the move to a non-ambulatory room, and there was insufficient evidence to substantiate the allegation.

The complaint alleging the facility was not keeping copies of the last 30 days of menus was investigated and found to be unsubstantiated.

The investigation found that a binder containing menus from 1/30 to 3/5 was available and staff stated that 6 weeks of past menus are always kept. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility administration was telling a resident he must change his insurance to the facility insurance company, potentially causing loss of dental and vision coverage and out-of-pocket expenses. The allegation was unsubstantiated after interviews and file reviews.

The investigation found no evidence that the facility forced residents to change their insurance. Staff and residents denied the allegation, and it was determined there was insufficient evidence to substantiate the complaint.

The complaint alleged lack of supervision resulting in inappropriate interactions between residents. The allegation was unsubstantiated after investigation.

The investigation found that staff levels were sufficient on the date of the incident and interviews revealed no indication of inappropriate interactions between residents. The allegation was unsubstantiated due to lack of preponderance of evidence.

The facility was found to be in compliance with all applicable regulations. No deficiencies were observed during the visit. The physical plant, infection control procedures, medication storage, and resident and staff records were all satisfactory.

The complaint investigation was unsubstantiated. Allegations included a resident being pushed by another resident, staff allowing residents to smoke inside the facility, and a resident not being accorded a healthful accommodation. Interviews and document reviews did not corroborate these allegations.

The investigation included interviews with staff, residents, and the administrator, as well as review of facility documents. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.

The complaint involved allegations that a resident changed another resident's diaper due to staff neglect, inadequate record keeping of diapering logs, staff not meeting residents' diapering needs, and staff failing to prevent a resident-on-resident altercation. The investigation concluded the allegations were unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegations. Residents and staff interviews, as well as record reviews, indicated that the alleged incidents either did not occur or lacked sufficient proof.

The complaint alleged that staff pushed a resident. Interviews with staff and residents present during the incident did not corroborate the allegation. The allegation was determined to be unsubstantiated.

The investigation found no preponderance of evidence to prove the alleged violation occurred, and the allegation was unsubstantiated.

The complaint alleged that on 10/23/2021, a resident's diaper had not been changed and they were left in soiled clothing. The allegation was unsubstantiated based on interviews and observations.

The investigation found insufficient evidence to substantiate the allegation. Staff and resident interviews, as well as file reviews, indicated that the resident chose to wear a diaper and staff regularly offered assistance, but the resident preferred to use the diaper instead of getting out of bed.

The complaint alleged that staff did not assist a resident with receiving medication. The investigation included interviews with staff, residents, and the resident's family. It was determined that staff assisted the resident and took appropriate actions when medication was refused. The allegation was unsubstantiated.

The investigation found that staff were aware of the resident's refusal of medication and took appropriate steps including contacting the physician and police when behavior escalated. The allegation was unsubstantiated due to lack of preponderance of evidence.