191502216-7-30-2026-28-AS-DSIS-DWWS42-20260813133201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191502216
Report Date: 07/30/2026
Date Signed: 07/30/2026 01:06:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260723175816

FACILITY NAME:	ROYAL OAKS		FACILITY NUMBER:	191502216
ADMINISTRATOR:	ANDREW M SMITH		FACILITY TYPE:	741
ADDRESS:	1763 ROYAL OAKS DRIVE		TELEPHONE:	(626) 359-9371
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	250	CENSUS: 213	DATE:	07/30/2026
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Sev Tienda - Wellness Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident was touched inappropriately by another resident due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation to investigate the allegation listed above. LPA met with Wellness Director Sev Tienda and explained the reason for the visit.

The investigation consisted of the following:

LPA obtained copies of Staff and Resident Rosters, Police Report Number for local police departments investigation on same allegation, and conducted interviews with 2 staff and 10 Residents.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260723175816

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS	FACILITY NUMBER: 191502216
	VISIT DATE: 07/30/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Resident was touched inappropriately by another resident due to staff neglect
It is alleged that R1 was touched on their breast by R2 and staff did not prevent this from happening. LPA attempted interview with R1, however, R1 refused to be interviewed after multiple attempts. LPA interviewed R2 and it was explained that there was no inappropriate touching, R2 stated they did visit R2 frequently due to R2’s health decline and they just would visit to keep R1 company every so often since they were in bed and not able to participate in activities. R1 stated that they gave a hug to R2 and gave R2 a kiss on the cheek goodbye at the end of a visit, which was normal interaction for both residents, but nothing was ever forced or done in an inappropriate manner. LPA interviewed 10 residents and each denied the allegation and stated they have never been touched inappropriately by any resident or staff and feel safe at the facility. LPA interviewed 2 staff and both denied the allegation and stated that this was brought to their attention by R1 psychiatrist and the facility cross reported to ombudsman, police and licensing after this information was obtained. Facility conducted an investigation as well as the local police department and both residents denied any inappropriate touching, R1 told stated that they were not touched, however, there was a consensual kiss shared with R2. S1 and S2 stated since this incident the care plan for R1 has been updated and both residents have been informed that it would be best for there to no longer be any in room visits to avoid these incidents from reoccurring, and families were contacted, made aware and agree to this plan as well.

Based on statements and interviews conducted with staff/residents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

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