198602564-3-4-2022-28-AS-LHIS-CCXPUW-20220328113809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 03/04/2022
Date Signed: 03/04/2022 04:51:45 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
03/03/2022 and conducted by Evaluator Noemi Galarza

COMPLAINT CONTROL NUMBER: 28-AS-20220303150219

FACILITY NAME:	ROYAL VISTA SAN GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	REGINA AGUILAR-GUEVARA		FACILITY TYPE:	740
ADDRESS:	901 W SANTA ANITA ST		TELEPHONE:	(626) 289-8889
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91776
CAPACITY:	100	CENSUS: 43	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Regina Guevara, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are failing to administer resident's medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Administrator Regina Guevara.

The investigation consisted of: LPA toured the interior of the facility, Memory Care Unit, and audited resident's medications. Staff (S1-S5), residents (R1-R7), and R1's pharmacy were interviewed. The following documents were obtained: resident (R1's) Face Sheet, Physician Report, Medication Administration Reports [Jan 2022- March 2022], LIC 500 Personnel Report, and resident roster]. LPA requested copies of the Plan of Operation and staff job descriptions, but did not obtain the documents because Administrator does not have copies. As a result, a case management deficiencies report was created.

See LIC 9099C for report continuation.

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20220303150219

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: 03/04/2022

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
26
27
28
29
30
31
32

Allegation: "Staff are failing to administer resident's medications." Based on record review and interviews conducted the findings indicate that Memory Care unit resident (R1) has not been administered 13 medications ordered by physician since March 1, 2022; a total of 4 days. The facility failed to obtain refill medications from the resident’s pharmacy. According to staff interviews, cycle medications are automatically refilled by the pharmacy on a monthly basis, and/or more often when there is new physician orders. LPA spoke to R1's pharmacy and was informed that the medications were not delivered as a result of non-payment of $ $528.55 since September 2021.The findings indicate that the pharmacy provided the facility a 10-day notice of discharge on February 17, 2022, and spoke to facility staff on February 28, 2022 regarding non-receipt of payment. Facility was informed that medications would not be filled for the month March unless payment was received. The pharmacy has not been paid as of today. A total of 7 residents were interviewed; of which one (1) resident stated that it ran out of one medication last week, and was filled 1 day late.

Resident (R1) is a Dementia resident without a public guardian or family. However, R1 confirmed that it has not received medications this week. Therefore, it is the facility's responsibility to ensure that R1's medications are filled in a timely manner, so there is no lapse in medication administration, and that the medications are paid for. Medications were audited during today's visit, and none of R1's medications were at the facility. Resident (R1) has hypertension and is diabetic. Which poses an immediate health, safety or personal rights risk to persons in care.

Per Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right. 87465(a)(4) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

Based on record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 08. See LIC 9099D.

An exit interview was conducted with Administrator Regina Guevara. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220303150219

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: 03/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/05/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Administrator shall obtain R1's medications immediately (no later than 24 hours) from the pharmacy. In addition, all med-tech staff shall be trained in their job responsibilities, and medication administration procedures. Submit proof of correction by tomorrow.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on record review, R1's Medication Administration Record showed evidence of no medication administration beginning March 1, 2022, due to non-payment. This poses an immediate 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
	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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3