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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 08/04/2020
Date Signed: 08/04/2020 03:34:59 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
03/10/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200310164010
FACILITY NAME:ROYAL VISTA SAN GABRIELFACILITY NUMBER:
198602564
ADMINISTRATOR:FUENTES, SUSANAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 78DATE:
08/04/2020
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Susana FuentesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff slaps residents in care.
Staff yell at residents in care.
Staff are utilizing unsanitary food service procedures.
INVESTIGATION FINDINGS:
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***This report serves as an amendment and supersedes the complaint investigation report created on 7/21/20. The complaint investigation findings have not been changed.***

Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Susana Fuentes.

Investigation consisted of the following: During the initial telephonic visit conducted on 3/20/20, LPA Gonzalez received a copy of Staff and Resident Rosters by email and interviewed Executive Director Susana Fuentes. On 5/5/20, LPA Mary Flores conducted telephone interviews with Residents 1-7 (R1-7), Caregivers

(See LIC 9099C for continuation of report)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
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-20200310164010
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: 08/04/2020
NARRATIVE
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Maria Perez, Page Lanyania and Angelica Polanca. LPA Flores also interviewed Kitchen staff: Daisy Lopez and Eugenio Alidio. On 6/11/20, LPA Flores requested the following documents: Face Sheets, Physician’s Report, Needs and Services Plan for R1-7. On 7/30/20, LPA Mary Flores conducted continuation of resident interviews via Facetime with R1-7 and conducted a virtual tour of facility kitchen and dining room via Facetime with Executive Director Susana Fuentes. On 8/3/20, LPA Gonzalez, interviewed Executive Director Susana Fuentes and conducted an additional Facetime video tour of the facility kitchen which included observations of two (2) facility refrigerators and one (1) freezer. LPA Gonzalez also requested and received copies of facility menus for four (4) weeks, two (2) alternative menus, Snack Schedule and Commission on Dietetic Registration Credential Verification for facility dietician.

The investigation revealed the following: In regard to allegations, Staff slaps residents in care and Staff yell at residents in care, it is alleged that a staff working at the facility slap residents on their hands when the residents sit at the dining room table and staff yell at the residents aggressively when residents reach for their utensils. Interviews conducted with R1-2 and R4-7 revealed that they are satisfied with the treatment received from facility staff and their interactions with staff. R1-2 and R4-7 stated that staff are nice, respectful and do not speak to them in loud tones. Interviews conducted with 6 out of 7 residents stated that staff are helpful, nice, and staff seem to enjoy their job and residents did not state any concerns regarding their interactions with facility staff. R2 stated that they have never seen staff physically abuse any resident at the facility. R6 stated they have not witnessed any staff physically abuse any resident at the facility and stated that staff are gentle. R3 was unable to answer interview questions due to cognitive challenges. Interview conducted with Executive Director Susana Fuentes revealed that staff treat all residents with dignity and respect and denied that any staff at the facility yell or physically hurt residents. Executive Director stated that facility residents are very outspoken and they come to her with any concerns they have regarding the staff or facility and she has never heard such allegations from any resident. Staff interviews conducted on 5/5/20 by LPA Flores revealed that staff consider having good relationships with residents and staff stated that they are aware that if they observe or know of any instances of residents being mistreated by staff or their personal rights being violated they know that they are mandated reporters and are aware of mandated reporting requirements. Based on LPA interviews conducted with facility staff and residents and LPAs review of staff training records, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Staff are utilizing unsanitary food service procedures, it is alleged that meat that is served to residents is undercooked and is served raw. It is also alleged that a facility cook was sick and facility
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200310164010
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: 08/04/2020
NARRATIVE
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cook did not wear a mask or gloves, coughed and sneezed while preparing the food and the cook's fingers kept going into the soup while the staff was passing out soup to the residents. Interview with Executive Director Susana Fuentes revealed that all kitchen staff wear gloves at all times while preparing the food and when they distribute the food. Executive Director stated that all staff are now mandated to wear a mask and that kitchen staff wear a mask at all times. Executive Director stated that all staff are properly trained and since the facility is being more cautious due to COVID-19 all staff including kitchen staff are wearing masks and gloves at all times. Executive Director stated that she has not received any complaints from any resident reporting that food is undercooked and/ or raw when served, no reports of servers not using gloves while serving food or that the servers fingers are going into their food as it is being passed out. Executive Director stated that the facility has a dietician that reviews and approves the facility menu on a monthly basis. Interviews with 2 out of 7 residents revealed that food servers use gloves when serving food. 4 out of 7 residents said that kitchen staff use a mask. Staff interviews conducted on 5/5/20 by LPA Flores revealed that staff use face masks since the beginning of March 2020 and kitchen staff have always used gloves while preparing food and while serving food to residents. On 7/30/20, LPA Flores conducted a virtual tour of facility kitchen and dining room and observed two (2) facility staff wearing masks and gloves and observed one (1) staff/server not wearing a mask while the staff/server was unpacking boxes and working by herself. There were no residents present or any other staff around as the staff member was working. On 8/3/20, LPA Gonzalez conducted a virtual tour of the facility kitchen and observed the kitchen to be clean and also observed three kitchen staff wearing masks and gloves as they were preparing a meal. LPA Gonzalez observed the temperature readings for two (2) refrigerators and one (1) freezer. The temperature readings for both refrigerators was 40 degrees F and 0 degrees F for the freezer. All three readings were observed from dial thermometers that were inside of each kitchen appliance. All reading met Title 22 regulations. LPAs review of staff training revealed that kitchen staff have completed 40 hours of training on Proper Food Handling and LPA also reviewed facility menus and observed that the facility serves well balanced meals with a selection of fruits and vegetables and an alternative menu was also reviewed. Based on LPA observations, LPA review of facility menus, alternative menus, snack schedule and Commission on Dietetic Registration Credential Verification for facility dietician, review of staff training records, and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Susana Fuentes.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3