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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:03:10 PM


Document Has Been Signed on 01/26/2023 04:03 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: 41DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Chia Demurjian, AdministratorTIME COMPLETED:
03:40 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 conducted a Case Management- Incident visit to follow up on an incident report submitted to the District Office on 1/22/2023. LPA met with Administrator Chia Demurjian. The purpose of today's visit is to check on the health & safety of residents in care and to issue a citation in regards to the neglect of care.

On Sunday January 22, 2023 at 7:10 AM, registry caregiver staff (S1) took Dementia resident (R1) inappropriately dressed into the dining room for breakfast. Resident (R1) was sitting in it's wheelchair with briefs, and pants down around the thighs. Another registry caregiver staff (S2) on duty addressed the concern with S1, but the staff walked away and left the resident unattended. Approximately 10 minutes later staff (S1) returned and began feeding R1. Staff (S3) noticed that S1 was force feeding the resident and shoving food in it's mouth. When the feeding was completed, staff (S1) left to get a clean shirt for the resident. At that point, staff S2 observed that the resident still had food in it's mouth. Staff (S2) removed the food in the resident's mouth in order to prevent choking or food aspiration. Staff (S1) returned to put a shirt on the resident. Shortly after other staff noticed the resident had blood on it's elbow. Of note, the resident does not have teeth and does not wear dentures.

The resident received first aid and Wellness Nurse sent registry staff (S1) home. Facility notified the registry staff agency, and has not worked at the facility since January 22, 2023, and staff in-services were provided to staff. The facility reported the incident to APS, Police, and Ombudsman.

A deficiency was cited according to Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right 87468.1 Personal Rights of Residents in All Facilities.



An exit interview was conducted with 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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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 01/26/2023 04:03 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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited

1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
1
2
3
4
5
6
7
Administrator shall submit:
1. Staffing plan addressing insufficient staffing
2. Staff in-service training with Topic and staff signatures
3. Copy of S1's disciplinary action
4. Proof of incident report submitted to registry staffing agency
8
9
10
11
12
13
14
Based on interviews conducted and document review, registry staff (S1) abused resident (R1) by not dressing the resident appropriately when taking it to the dining room, and force feeding the Dementia resident without regard to choking or apiration. This poses an immediate health and safety 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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2