198602564-1-26-2023-28-AS-LHIS-CNPUTL-20230203145204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:19:30 PM

Substantiated

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
11/09/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201109094754

FACILITY NAME:	ROYAL VISTA SAN GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	FUENTES, SUSANA		FACILITY TYPE:	740
ADDRESS:	901 W SANTA ANITA ST		TELEPHONE:	(626) 289-8889
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91776
CAPACITY:	100	CENSUS: 41	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Chia Demurjian, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff failed to provide access to resident's records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. LPA met with Administrator Chia Demurjian.

The investigation consisted of the following: On 11/17/2020, Administratror/staff (S1) & staff (S2) were interviewed. Documents pertaining to resident (R1) were requested but not received on that date. Administrator Susana Fuentes stated that she did not get approval from the corporate office to provide to CCL the requested documents. On 11/19/2020, the following documents were received: Identification and Emergency Information/Face Sheet, Admission Agreement, Physician Report, Appraisal/Needs and Services Plan, Home Health records, Medication Administration Records [Medication Administration Records (MAR) January 2020- August 2020], Power of Attorney documents, caregiver notes, physician orders, psychiatry progress notes, skin body checks, care plan, LIC 500 Personnel Report, and resident roster.

See LIC 9099C for continuation of report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201109094754

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: 01/26/2023

NARRATIVE

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Allegation: Staff failed to provide access to resident's records. It is alleged that on October 22, 2020, the facility received via fax and U.S. mail a formal medical records request pertaining to resident (R1). A prior records request was sent via fax and U.S. mail on October 13, 2020, to the Skilled Nursing Facility (SNF) "Royal Vista Care Center" next door regarding R1. That request had the incorrect name and address listed, but had Royal Vista San Gabriel's correct fax number and resident (R1's) name. On both request dates aforementioned, the records were to be provided within two (2) business days as required by California Health and Safety Code 1569.269(21).

Based on record review, the findings indicate that the initial request was addressed to the incorrect facility name/address/type, but was faxed to this Assisted Living facility with the correct resident's name. The SNF next door and this facility are owned by the same licensee. Therefore, have direct daily communication pertaining to administrative matters. Per former Administrator interview, Ms. Fuentes confirmed the records request was received on Oct. 13, 2020, and that they were provided to the facility's corporate office staff within 2 days. Former Resident Care Coordinator stated that the records were provided to the Administrator one (1) day later, and they were given to the corporate office staff. Both staff (S1 & S2) stated corporate staff were responsible in providing the resident records to the legal representative. Per staff interviews, the records were provided to the facility corporate office staff. However, as of October 28, 2020 the resident's records had not been provided to the legal representative. Therefore, based on document review there is sufficient evidence to corroborate the allegation.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights. See LIC 9099D.

Exit interview was conducted with Administrator Chia Demurjian. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201109094754

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2023 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agreed submit a written plan of correction addressing resident records, enumerated rights; severability, and facility procedures regarding resident records request. Submit by POC due date.
	8 9 10 11 12 13 14	Based on record review, the facility received a formal medical records request on 10/22/2020, and failed to provide the records within 2 business days, as required per regulation; which poses a potential 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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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