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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:28:10 PM


Document Has Been Signed on 01/20/2023 12:28 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:CHIA Y. DEMURJIANFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 39DATE:
01/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chia Demurjian, AdministratorTIME COMPLETED:
12:30 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 made an Unannounced Case Management- Deficiencies visit pertaining to non-reporting of COVID-19 outbreak and Administrator Changes. LPA met with Administrator Chia Demurjian and Wellness Nurse Elizabeth Contreras. A physical plant inspection was conducted today.

On January 5, 2023, the Memory Care Unit had positive resident and staff cases. The COVID-19 cases were reported to Community Care Licensing (CCL) until January 10, 2023. A total of 17 Memory Care residents and 4 staff tested positive for COVID-19 virus. Administrator failed to report to CCL the COVID-19 outbreak within 24 hours, and did not notify/report any cases to LA County Department of Public Health (DPH). On January 17, 2023, CCL informed Administrator that all COVID-19 cases must be reported to the Department of Public Health.

  • Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(2) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

Additionally, former Administrator Regina Guevara stopped working at the facility on October 4, 2022. Licensee and Administration staff did not report to Community Care Licensing of the change. As of January 17, 2023, the former Administrator was still listed as the Administrator on record. On January 17, 2023, CCL received incomplete Change of Administrator documents appointing Chia Demurjian as Administrator.
  • Per Title 22, Title 22, Division 6 Chapter 8 Article 07. Personnel Administrator Recertification Requirements. 87407 (k)(1) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated.
Deficiencies were cited. Exit interview was conducted with 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: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 01/20/2023 12:28 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
Section Cited

1
2
3
4
5
6
7
Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours.....
1
2
3
4
5
6
7
Administrator shall submit a written plan of correction that includes:
1. Review/revise the Infection Control Plan and submit an updated ICP by tomorrow.
2. Conduct staff training and provide proof that all staff were trained in Infection Control
8
9
10
11
12
13
14
This requirement was not met evidenced by:
On 1/5/2023, the facility had 21 COVID-19 positive cases that were not reported to CCL or Dep. of Public Health (DPH) within 24 hours. They were reported to CCL until 1/10/23, and to DPH until 1/17/23; which poses an immediate health and safety risks to persons in care.
8
9
10
11
12
13
14
Type B
01/20/2023
Section Cited

1
2
3
4
5
6
7
Personnel Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office .....
This requirement was not met evidenced by:
1
2
3
4
5
6
7
On 1/17/23, Administrator submitted incomplete change of Administrator documents to CCL.

Administrator agreed to submit the following pending documents:
1. Licensee letter
2. LIC 503
3. LIC 308
8
9
10
11
12
13
14
On 1/17/2023, LPA was informed by current Administrator that former Administrator stopped working at the facility. The former Administrator was discharged on Aug. 1, 2022. Licensee & Administrator failed to report to CCL of the change within 30 days. This poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2