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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 07/23/2021
Date Signed: 07/23/2021 05:07:45 PM

Document Has Been Signed on 07/23/2021 05:07 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:FUENTES, SUSANAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 100CENSUS: 48DATE:
07/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marina Galaviz, Resident Care CoordinatorTIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Galarza and Wong conducted an unannounced case management visit to the facility to perform a health and safety check of facility and residents in care. Upon arrival, LPA met with Marina Galaviz explained the purpose of the visit. The facility is licensed to serve 100 residents over the age of 60 (100 Non-Ambulatory & 10 bedridden). The facility has a Dementia Waiver and an approved Hospice Waiver. Administrator on file Susana Fuentes has been on leave since May 10, 2021. Ms. Fuentes resigned on July 18, 2021. Corporate staff Brenda Nicolas arrived at the end of the visit.

OBSERVATIONS:

At 12:00 PM, LPAs and Administrator toured the interior and exterior physical plant. LPA inspected:
  • Assisted living floors and Memory Care unit were toured.
  • LPA conducted a random tour of resident rooms. Residents were interviewed.
  • Kitchen/dining room & food supply. Sufficient supply of perishable food was observed, but non-perishable food supply was not sufficient. NOTE: Facility does not have registered dietician or a dietary director.
  • Medication room was locked and inaccessible to residents.
  • Interior physical plant was inspected. The flooring in the 1st floor Memory Care Unit is need of repairs. The laminate flooring is lifting posing a tripping hazard for residents in care.
  • Staff schedules were observed. Staff were interviewed and staffing shortages were confirmed.
  • LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.
  • One (1) caregiver was observed in Assisted Living floors and 2 caregivers in the Memory Care Unit were observed during the AM shift. Today's PM shift will have 2 Assisted Living caregivers, and 2 Memory Care Unit caregivers and one Activity Assistant.
  • On 7/22/2021, the facility only had one (1) caregiver and one (1) med-tech staff for the entire building during the PM shift. Security guard had to assist with resident supervision.
  • Marina Galaviz stated that two new staff are scheduled to start working tomorrow, and registry staff will work on Sunday.

See LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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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
VISIT DATE: 07/23/2021
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Documents obtained:

1. LIC 500 Personnel Report, weekly staff schedules for July 2021, and July 23- July 25 weekend schedule.
2. Resident Roster

NOTE: One Heart registry staffing agency was contacted. On Sunday July 25, 2021 two (2) registry staff will be working. Names of staff were not obtained.

Deficiencies were cited according to California Code of Regulations, Title 22. See LIC 809D.

Exit interview held with Resident Care Coordinator Marina Galaviz. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/23/2021 05:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/23/2021 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2021
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements - General.(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by evidence of:
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Licensee shall:
1. Contact registry staffing agency to obtain immediate staff assistance.
2. Submit a written plan addressing staffing shortages and plan of action.
3. Submit a copy of registry staffing contract and list of staff that will be working at the facility. ***POC due tomorrow.
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Based on observation and interviews conducted the facility failed to ensure there is sufficient personnel to meet the needs of residents in care. On 7/22/2021 only 1 caregiver staff worked in the PM shift [memory care]. No caregiver was available for Assisted living residents. Staffing shortages have not been addressed by Licensee. This poses and immediate health and safety risk to persons in care.
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Type B
07/30/2021
Section Cited
CCR87405(a)

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87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator....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.
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Licensee shall appoint a qualified Administrator and submit all required documentation to licensing by POC due date.

Submit a written plan and required documents.
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Based on interviews, observation, and record review the facility failed to appoint an Administrator after Administrator on record's extended absence. Designee Marina Galaviz assummed Administrator responsibilities in May 2021.
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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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2021 05:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/23/2021 at 03:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited
CCR
87555(b)(17)

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87555 General Food Service Requirements. In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian ... shall be made for regular consultation from a person so qualified.
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Licensee shall hire a facility dietary supervisor and dietician are required per Title 22.

Submit a written plan of correction and proof that staff were hired.

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Based on observation and interviews conducted the facility has not had a dietary supervisor or dietician consultant in years. Currently the dishwasher is is responsible for creating the food menu, cooking, ordering food inventory supplies, cleaning, and serving. There are residents that require special diets. Staff confirmed no special diets are being cooked.
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Type B
08/13/2021
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met by evidence of:
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Licensee shall repair and/or replace the flooring in the Memory Care Unit.

Submit picture proof of corrections by POC due date.
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Based on observation during physical plant inspection in the Memory Care Unit the laminate flooring was observed to be in major disrepair. The laminate flooring was raised and sticking out. The floors has a temporary fix of duct tape in some areas. This poses a potential health and safety risk to residents in care.
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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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


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