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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:18:23 PM


Document Has Been Signed on 03/24/2023 04:18 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: 48DATE:
03/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Elizabeth Contreras, Wellness NurseTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza made an unannounced Case Management-Deficiencies visit for the purpose of an unrelated complaint investigation control # 28-AS-20230321092912. LPA met with Wellness Nurse and explained the purpose of this report.

During today's, complaint visit LPA was informed that Administrator Chia Demurjian is not available due to short term leave, with unknown date of return. Ms. Demurjian last worked at the facility on February 17, 2023. The Licensee did not find a temporary replacement and designate responsibility to another person in order to ensure the facility is in compliance. In addition, Community Care Licensing was not notified of the Administrator’s absence.

Deficiency is cited per California Code of Regulation Title 22. See LIC809-D.



Exit interview held with Wellness Nurse Elizabeth Contreras. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2023 04:18 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: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited

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Administrator - Qualifications and Duties.
All facilities shall have a qualified and currently certified administrator....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as
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Licensee shall find a temporary replacement and designate responsibility of facility management. Submit proof of correction by POC due date.
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 specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. Administrator last worked at the facility on Feb. 17, 2023, and no designee has been appointed, nor was CCL notified.
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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: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
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