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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 07/14/2021
Date Signed: 07/14/2021 02:34:36 PM

Substantiated


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
07/09/2021 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20210709153106
FACILITY NAME:ROYAL VISTA SAN GABRIELFACILITY NUMBER:
198602564
ADMINISTRATOR:FUENTES, SUSANAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marina Galaviz TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
Inadequate staff resulting in resident's needs not being met.
INVESTIGATION FINDINGS:
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On the above date, Licensing Program Analyst (LPAs) Chrstine Wong and Alberto Lopez conducted the initial 10 day complaint investivation. LPAs met with Marina Galaviz-Resident Care Coordinator and explained the reason the visit, she also assisted with the visit.

The investigation consisted of the following: On today's visit, LPAs interviewed six (6) residents (R1-R6)and four (4) staff (S1-S4) and reviewed five residents file, medication and medication administrative record (MAR).

The investigation revealed of the following: Allegation#1 "Staff mismanaged resident's medication." LPA interviewed six (6) residents, they reported medication was not given on time or sometimes staff forgot to give them medicaton. LPA reviewed the MARs and all five (5) residents' MARs were missing staff initials. LPA also reviewed R1's medication and observed all her morning medicationa for day 15th in the bubble pack was taken out in error and then put it back into the original package. (See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20210709153106
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: 07/14/2021
NARRATIVE
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Besides that, while the staff put R1's medication into the original package and one of the medication (Potassium 10meg) was missing. In addition, LPA also observed all R2's medication which included Zinc 50mg, Multinvitamin, Sertraline HCL 50mg and Omerprazole Dr 20mg. was missing on the day 15th due to staff put the medication in the cup and accidentally dropped all the medication and staff needs to reorder all the medication for R2 for day 15th. For the PRN medication, the staff was not able to locate R1, R2 and R3's PRN medication in the facility and it was not there since July 1, 2021. For R4, three of her medications (Amlodipine, Rourvastain Calcium 5mg and Montelukast Sodium 10mg) did not dispense for the day 12th and 13th and were still in the bubble pack.

Allegation#2 " Inadequate staff resulting in resident's needs not being met." LPA interviewed six (6) residents, one of them refused to be interviewed, three of them reported the facility has inadequate staffing. It took very long for staff to come and assist them. Staff sometimes would forget their needs like showering or giving them medication and would assist them next day or next week for showering or give the medication to them later time or even forget sometimes. LPA also interviewed staff and all admitted they are under staff at the present time and they are in the process of hiring more staff. The staff also reported the inadequate staffing had been an ongoing issues and they only have two caregivers for memory care unit at night shift and one caregivers for assisted living unit.

Based on document review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Resident Care Coordinator Marina Galaviz A copy of the report an appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210709153106
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2)Incidental Medical and Dental Care if the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.
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Licensee shall submit a copy of written medication administration protocols, and a plan that addresses the medications errors. In addition, all med-tech staff shall obtain medication training from a pharmacy.
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The requirement is not met as evidenced by reviewing record, LPA observed all R1's morning medication on the bubble pack on day 15th was taken out in error and then put them back on the original package. Also R2's day 15th medication was missing due to staff accidently dropped which posed an immediate risk to residents
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Type B
07/28/2021
Section Cited
CCR
87411(a)
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87411(a)Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care
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Licensee shall submit a plan for how to able to provide the services necessary to meet residents needs or provide the hiring plan for the insufficient number of staff.
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The requirement is not met as evidenced by conducting interiew. Staff reported they are currently under staffing and residents reported they did not get their medication sometimes or showering due to short staff which impose a potenital risk to resident in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3