198602564-6-24-2021-28-AS-LHIS-C76U2D-20210924151144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 06/24/2021
Date Signed: 06/24/2021 05:10:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/21/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210421093846

FACILITY NAME:	ROYAL VISTA SAN GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	FUENTES, SUSANA		FACILITY TYPE:	740
ADDRESS:	901 W SANTA ANITA ST		TELEPHONE:	(626) 289-8889
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91776
CAPACITY:	100	CENSUS: 47	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	Marina Galaviz, Resident Care Coordinator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident's room is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit and delivered findings.The purpose of the visit was explained to Resident Care Coordinator Marina Galaviz.

The investigation consisted of the following: On 4/29/2021 due to the COVID-19 pandemic a telephonic visit was conducted. LPA was not able to conduct a virtual physical plant inspection on that date because there was no Administration staff available to assist. Administrator/staff (S1) was interviewed via phone on 5/5/2021. On 5/12/21, resident (R1) and staff (S2) were interviewed and R1's room was observed during site visit. Random resident rooms were inspected. Resident (R1) file documents were obtained [ Identification and Emergency Information, Physician Report, Appraisal, Assisted Living Waiver ISP Plan, Resident Personal Property and Valuables list, "Medication Verification Form", Physician Order, LIC 613-C-2, Admission Agreement, resident roster, Medication Administratiom Records, and staff contact information/LIC 500 Personnel Report. During today's visit, staff (S3-5) and residents (R2-R5) were interviewed.

See LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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-20210421093846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL VISTA SAN GABRIEL	FACILITY NUMBER: 198602564
	VISIT DATE: 06/24/2021

NARRATIVE

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Allegation: "Resident's room is in disrepair." Based on interviews conducted resident (R1) selected the room and reported to staff issues with the room such as broken shower head and broken lamp. Staff responded to complaints and determined the shower was not broken, but rather the shower head was a hand held shower head that hangs. The room lamps were not to the resident's liking and they were switched several times. Based on observations during the physical plant/random room inspection no disrepair was noted. None of the residents interviewed reported issues with room or facility disrepair. All staff interviewed stated that rooms are repaired prior to a resident moving in to the room. Maintenance staff and Activity staff were present the day resident (R1) moved in and conducted a room check. No room disrepair was noted.

Based upon interviews conducted, and observations made the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Marina Galaviz. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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