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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 01/11/2022
Date Signed: 01/11/2022 01:41:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GABRIELFACILITY NUMBER:
198602564
ADMINISTRATOR:REGINA AGUILAR-GUEVARAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 47DATE:
01/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Regina Aguilar-GuevaraTIME COMPLETED:
01:40 PM
NARRATIVE
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1/11/2022 Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 1/11/2022 during a complaint investigation. LPA met with administrator, Regina Aguilar-Guevara and stated the purpose of the visit.

During the visit the following deficiency was observed:
  • 1/11/2022 11:20 a.m. LPA was not screened for COVID-19 symptoms or temperature check by security guard or staff.


This is a repeat violation from 5/12/2021. Civil Penalties assessed in the amount of $250 for repeated violation.

Deficiencies cited under California Code of Regulations, refer 809-D



Exit Interview conducted, copy of report and appeal rights provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities...personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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1/11/2022 11:20 a.m. LPA was not screened for COVID-19 symptoms or temperature check by security guard or staff. This is a repeat violation from 5/12/2021. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2022
LIC809 (FAS) - (06/04)
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