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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:40:19 PM

Unsubstantiated


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
01/07/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220107134705
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: 41DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Regina Aguilar-GuevaraTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Facility did not transport resident to medical appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Regina-Aguilar Guevara and explained the reason for the visit.
The purpose of the visit is a subsequent visit to deliver the findings from the original complaint dated 1/7/2022.
At visit 4/13/2022 at 10:05 AM Administrator Regina-Aguilar Guevara was interviewed.
Resident's 1-3 were interviewed from 10:20 AM to 10:50 AM.
Case Manager for Resident 1 was interviewed telephonically at 11:00 AM.
At visit 1/11/2022 LPA obtained copies of; staff roster and client roster, physician report for Residents #1-2 (R1-R2), and daily notes for the months of December 2021 and January 2022 for Residents #1-4(R1-R4). LPA requested physician report for Resident #3-4 (R3-R4) to be emailed to LPA by 5 PM. on 1/12/2022.
In regards to the allegation Facility did not transport resident to medical appointments, based on the interviews conducted and information gathered Client C1 stated that dialysis is 3 times a week and facility has not missed his appointments. Stated he has not missed appointments. Client's C2 and C3 said they are picked up and go all the time to dialysis.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 2
Control Number 28-AS-20220107134705
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: 04/26/2022
NARRATIVE
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Staff interviewed stated that C1 had refused a couple of times because he said it made him tired and weak.
Med- Tech interviewed stated that Caregiver had alerted her that C1 had refused to go to dialysis and it was documented.
Case Worker for C1 confirmed that dialysis would not let C1 return until he visited a cardiologist.
Daily Screening Log For Residents, Visitors and Medical Providers notates the following:
On 12/27/2021 at 11:37 AM C1 back from dialysis.
On 12/29/2021 at 11:45 AM C1 back from dialysis.
On 12/30/2021 at 7:52 AM C1 left to dialysis.
On 12/31/2021 at 10:00 AM C1 back from dialysis.
There are also numerous entries for C2 and C 3 going and coming back from dialysis.
Daily Notes from the facility document the following:
C 1 on 1/7/2022 went to dialysis at 4:30 AM.
C 1 on 1/6/2022 back from dialysis.
C 1 on 1/4/2022 back from dialysis at 9:10 AM.
C 1 on 1/3/2022 went to dialysis at 4:30 AM
C 1 on 12/31/2021 back from dialysis at 10:00 AM.
C 1 on 12/28/2021 refused dialysis and primary care provider notified of C1's refusal.


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

An exit interview was conducted with Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2