complaint·December 4, 2025

During today’s visit between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not report an incident to licensing.” It was reported that the facility did not notify Community Care Licensing (CCL) of an unwitnessed fall. On 07/26/2025, Resident #1 (R1) sustained an unwitnessed fall in their unit and was found on the floor by their bedside. The facility notified R1’s family and R1 was subsequently transferred to the hospital via Emergency Services. Interview with five (5) out of seven (7) staff revealed that they were unaware about the CCL reporting requirements, or if facility incidents were reported to CCL. Staff responsibilities include logging incidents in the facility’s electronic system and facility Administrators are responsible for the remaining steps. Interview with the ED noted that they “assumed Licensing received the report” of R1’s fall. When the LPA inquired about the details of the fall, the ED requested to review the copy the LPA obtained and provided information off the Incident Report. On 11/05/2025, the LPA conducted an unrelated complaint visit and addressed facility Incident Reports with the Office Manager Joey Vitug. The Office Manager is responsible for completing Incident Reports and sending them to CCL. They stated they utilize an App called Genius Scan that scans the Incident Reports which processes and automatically emails CCL the reports. During the visit on 11/13/2025, the LPA reviewed CCL’s record of Incident Reports received from 2024 to present with the ED, the incident on 07/26/2025 not included as it was not received. The ED expressed and confirmed that the record did not reflect the accurate number of incidents the facility has experienced. The LPA addressed the Genius Scan App and suggested that the facility email all reports to the Woodland Hills North Regional Office directly to ensure receipt and compliance. The ED agreed. Report Continued on LIC 9099-C Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Allegation: “Staff did not complete a personal property inventory for a resident in care.” It was reported that the facility did not complete a personal property inventory upon admission. Four (4) out of seven (7) staff reported the facility does not complete a personal property inventory upon resident admission and are unsure of the procedure. The ED confirmed that resident personal property inventory is only completed if the property is entrusted to the facility. The LPA reviewed Health and Safety Code Section 1569.153 Theft and Loss Program and CA Code of Regulations Section 87217 Safeguards for Resident Cash, Personal Property, and Valuables with the ED. Record review of five (5) resident records revealed that LIC 621 Client/Resident Personal Property and Valuables form and Theft and Loss Policy were included in the resident Admission Agreement on pages “RB RF-31” to “RB RF-34.” The LIC 621 on page RB RF-31 did not list the residents’ names and included typed notes stating “I have no property/valuables entrusted to Royal Bellingham at this time” and “NOTE: The Residences at Royal Bellingham will only inventory and provide the resident or responsible party with a copy of the resident’s personal properties/valuables as inventoried items if said items are entrusted to the facility and are stored in a secured area controlled by the facility. Any and all other personal properties or valuables are solely the responsibility of the resident and/or their responsible party.” Health and Safety Code Sections 1569.152, 1569.153, and 1569.154 on page RB RF-32 did not contain signatures of receipt. The facility’s Theft and Loss Policy on page RB RF-33 noted “The Administrator will be responsible for maintaining a record of each Resident’s personal property/valuables. Resident’s Personal Property and Valuables (Form 621) will be completed upon admission with the assistance of the Resident or Responsible Party” and “An inventory of personal property will be maintained by The Royal Bellingham.” Six (6) out of nine (9) residents confirmed a personal property/valuables inventory was not completed upon admission. Report Continued on LIC 9099-C Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (Refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. During today’s visit between 10:17AM and 1:35PM, the LPA conducted a physical plant tour and interviewed five (5) residents and four (4) staff. No immediate concerns were observed. The following was then determined: Allegation: “Staff did not prevent a resident from being locked outside for a long period of time” It was reported that on 11/02/2025 around 8:30PM, Resident #1 (R1) returned to the facility and was locked outside for approximately twenty-five (25) minutes. Interview with nine (9) residents revealed that they have not experienced, or observed other residents locked outside. Eight (8) staff reported residents waiting a maximum of ten (10) minutes and noted that response time is typically very quick when visitors and residents return to the facility late at night. The facility locks the exterior doors in the late evening, and visitors can utilize the doorbell/buzzer and call the facility phone number to gain entrance. Staff reported the doorbell to be heard easily in the night due to most residents resting and the facility being quiet. Additionally, staff carry a wireless phone which receives all phone calls made to the facility. Doorbell footage of the rear entrance on 11/02/2025 revealed that R1 approached the door at 8:42PM. R1’s family rang the doorbell at 8:43PM and was observed to subsequently ring the doorbell several times before attempting to call the facility phone number. At 8:47PM, Staff opened the rear door while R1 and their family entered the facility. R1 was at the rear entrance for approximately five (5) minutes before gaining entry. Although the allegation may have happened or are valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.