<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 03/04/2022
Date Signed: 03/04/2022 04:55:13 PM


Document Has Been Signed on 03/04/2022 04:55 PM - It Cannot Be Edited

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: DATE:
03/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Regina Guevara, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Galarza initiated a case management visit due to deficiencies found during a complaint investigation (Control #: 28-AS-20220303150219). The purpose of the visit was explained to Administrator Regina Guevara.

During the complaint investigation, LPA requested a copy of the Plan of Operation and staff job descriptions. Administrator was not able to find copies of the documents. Administrator started working at the facility on August 2021, and has not been able to find copies of the Plan of Operation in facility records since then.

Title 22, Division 6 Chapter 8 Article 04. Operating Requirements. 87208(a) Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.

LPA reviewed the file at the Regional Office and noticed the Plan of Operation and other documents have the old facility name "Vista Cove" that was owned by a different company. Licensee shall update the Plan of Operation and all applicable facility documents that list the old facility name. The documents shall be submitted to Community Care Licensing by plan of correction date.

Deficiency was cited. See LIC 809D.

An exit interview was conducted with Administrator Regina Guevara. A copy of the report and Appeal Rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/04/2022 04:55 PM - It Cannot Be Edited

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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited

1
2
3
4
5
6
7
Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility.....

This requirement was not met evidenced by:
8
9
10
11
12
13
14
Based on record review during complaint control #: 28-AS-20220303150219, LPA requested a copy of the Plan of Operation and staff job descriptions, but Administrator was not able to find copies in facility record files. This poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2