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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 05/31/2022
Date Signed: 06/07/2022 12:16:21 PM


Document Has Been Signed on 06/07/2022 12:16 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: 41DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Chia Demurjian, Assistant AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with med-tech Genesis Gonzalez and explained the purpose of the visit. Assistant Administrator Chia Demurjian arrived later. There are 41 residents ages 60 and above, of which 10 may be bedridden. The facility has a Memory Care Unit. A hospice waiver for 5 residents is in place. Facility is a 3- story building consisting of 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, and 2 courtyard patio areas. Administrator certificate expires 2/14/2023.

The following was inspected and observed during the inspection:
  • COVID-19 Infection Control Practices were observed in main entrance, and common areas. COVID-19 infection control signs were observed in all common rooms and hallways promoting hand washing, cough/sneeze etiquette, and social distancing. Hand sanitizers throughout the facility were observed.
  • Rooms 212 & 213 and Memory Care Unit rooms # 109, 110, & 111 are designated isolation rooms.
  • Twenty (20) resident rooms were inspected; of which five (5) were missing curtains, had broken blinds, and/or had sheer curtains that do not afford privacy.
  • Seven (7) centrally stored resident medication records were reviewed. SIx (6) out of seven (7) residents were missing 30-day supply of medications and/or physician ordered cycle medications. Resident (R1's) medications [total of 9] have not been filled since mid April 2022; which poses an immediate health and safety risk. Facility is responsible for ensuring that all residents get medication refills despite insurance coverage issues. Facility was provided a list of all medications that were missing.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
Deficiencies were cited. See LIC809D.

Exit interview was conducted with Assistant Administrator Chia Demurjian. 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: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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 3


Document Has Been Signed on 06/07/2022 12:16 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: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during medication review, the licensee did not comply with the section cited above in that six (6) out of seven (7) residents were missing 30-day supply of medications and/or physician ordered cycle medications. Resident (R1's) medications [total of 9] have not been filled since mid April 2022; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee shall ensure all missing medications are filled by tomorrow. In addition, all staff that dispense medications shall receive in-service training. This training shall be provided by pharmacy and/or registered nurse. Submit in writting how this was corrected and attach proof of training by tomorrow.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/07/2022 12:16 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: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in rooms 104, 107, 112, 121, 307, & 312 had sheer curtains and/or were missing curtains or blinds, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Licensee shall ensure all residents are accorded safe, healthful and comfortable accommodations, furnishings and equipment that afford privacy. Submit proof of purchase/corrections, and a written statement indicating which rooms had new curtains installed and/or blinds repaired.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3