198602564-1-26-2023-28-AS-LHIS-CNVR5X-20230209114351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:12:19 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
01/24/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230124134758

FACILITY NAME:	ROYAL VISTA SAN GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	CHIA Y. DEMURJIAN		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:	11:05 AM
MET WITH:	Chia Demurjian, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility is not properly managing resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the able allegation. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Chia Demurjian arrived later.

The investigation consisted of the following: A physical plant inspection of the facility was conducted. Staff (S1-S6) and residents (R1-R6) were interviewed. A total of six (6) medication records were audited; no errors were found today. Resident (R1) file documents were obtained [ Identification and Emergency Information, Physician Report, Medication Administration Records, LIC 500 Personnel Report, resident roster, and staff schedule were obtained. Resident (R2's) Medication Administration Records were obtained. A picture of the medication that was provided in error to R1 was obtained.

See LIC 9099C

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-20230124134758

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: Facility is not properly managing resident's medication. It is alleged that on January 22, 2023 at 2:00 PM, resident (R1) received resident (R2's) medication in error. Resident (R1) received all it's PM medications, and was given one (1) extra medication Velphoro 500 mg medication that belonged to resident (R2). The medication error was brought to the attention of the PM med-tech staff on duty (S7) on duty. Staff (S7) apologized and stated the medications were prepared by the previous day's PM med-tech staff (S1). A total of four (4) med-techs and two (2) administration staff were interviewed. Staff (S1) confirmed that it prepared/placed the resident's medications in small plastic cups the day prior, but denied making the medication error. Staff (S1) stated that it is unlikely that R2's Velphoro medication was placed in R1's medication cup because the medication is a large brown pill that looks different than all others. However, S1 stated that cups were rearranged by alphabetical order; which may have caused the error. A total of six (6) residents were interviewed. One (1) out six (6) residents confirmed the allegation. Resident (R1) stated that med-tech staff (S7) gave the resident another resident's medication. During today's visit, LPA reviewed a total of six (6) resident's medications and found no errors. Based on record review and a picture obtained of the medication that was administered in error there is sufficient evidence to corroborate the allegation.

Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.

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

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-20230124134758

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 A 01/26/2023 Section Cited CCR 87465)(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Administrator agreed to provide staff training to all med-tech staff by POC due date. Submit proof by POC due date. If an extension is needed submit by POC due date.
	8 9 10 11 12 13 14	Based on records review, on Jan. 22, 2023 med-tech staff gave resident (R1) resident (R2's) Velphoro 500 mg medication in error. R1 immediately reported the error, and the medication was not taken. 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 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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