198602564-5-1-2023-28-AS-MVAO-CRVNXY-20230516105155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:46:58 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
04/25/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230425105928

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: 54	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Nelida Arlante, Interim Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to provide a comfortable environment for residents in care.
Facility does not have an Administrator.
Facility is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to Administrative Assistant Sau Lee. Interim Administrator Nelida Arlante works next door at the Skilled Nursing Facility (SNF) and arrived later. Administrator on record Chia Demurjian is not available due to leave of absence.

The investigation consisted of the following: A physical plant tour of the facility with a focus on water supply/plumbing operation, facility maintenance, and Emergency and Disaster Plan responsibilities. A copy of LIC 610D Emergency and Disaster Plan, LIC 500 Personnel Report, resident roster. Staff (S1-S3) and residents (R1- R6) were interviewed. *Change of Administrator documents are still pending.

See next page.

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: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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 5

Control Number 28-AS-20230425105928

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: 05/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff failed to provide a comfortable environment for residents in care. It is alleged that on Sunday, April 23, 2023 at approximately 6:30 PM, the facility water supply was shut off. Residents did not receive notification of the reason for the water shut off because allegedly facility staff do not speak and/or are not able to communicate with residents in their Asian language. Facility staff in charge on the premises at the time of the incident were the security guard and med-tech staff. Per staff interviews, room #230's bathtub plumbing fixture could not be turned off. Maintenance staff was called and it directed the security guard to shut off all of the building water supply. Maintenance staff immediately returned to the facility and fixed the issue. Some residents were informed that the water would likely be restored until the following morning and were not able to provide emergency guidance or plan procedures. Other residents and their families were not notified of the issue. Interim Administrator stated it had no knowledge of the plumbing water incident that occurred. The findings indicate that facility staff on duty during the incident did not follow emergency policy procedure notification to residents and their responsible parties. The incident was resolved a couple of hours later.

Allegation: Facility does not have an Administrator. It is alleged that the facility has not had an Administrator since February 2023 because the Administrator has been on a leave of absence. The two staff in charge are the Wellness Nurse and Administrative Assistant and neither staff are certified Administrators. It is alleged that it is unclear whom is in charge of facility operations because families have not received notification of Administrator changes and Administrator Chia Demurjian has not responded to phone calls of emails. According to staff interviews, Administrator Ms. Demurjian has been on leave since February 17, 2023. Interim Administrator Ms. Nelida Arlante stated that she began working at this facility and the Skilled Nursing Facility (SNF) next door on February 1, 2023. However, on 3/24/2023 LPA visited the facility and an Administrator had not been appointed, nor was CCL notified of the Administrator changes. On 3/31/2023, facility staff submitted an incomplete change of Administrator document packet. As a result the Administrator on record has not been changed. Ms. Arlante confirmed she does not have an office at the facility and only makes quick rounds at the facility. Therefore, the Interim Administrator appointed is not on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. Per staff interviews, the Licensee asked the Wellness Nurse and Administrative Assistant to take RCFE Administrator education classes, but neither staff is yet certified and/or may not meet the qualification requirements. A total of six (6) residents were interviewed none of the residents are are that Ms. Nelida Arlante has been appointed the Interim Administrator. Two (2) out of the six (6) residents stated they think Administrative Assistant Sau Lee is the Administrator.

See next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230425105928

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: 05/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility is in disrepair. It is alleged that the facility has had plumbing issues since approximately April 2021. LPA conducted a physical plant tour of common areas and randomly selected resident rooms. A total of 17 resident rooms were inspected. Based on observation, the Dementia unit located in the 1st floor has laminate flooring that is in disrepair in the main hallways; which poses a tripping hazard to residents in care. Six (6) out of the 17 rooms had heavily stained carpets. In addition, the 2nd floor carpet near the administrative offices is torn. Several resident room doors need repairs. According to staff, residents that use wheelchairs bump the doors when entering their room, therefore have damaged the doors. Staff were interviewed and acknowledged the facility needs repairs. In regards to the Dementia (1st floor) laminate flooring disrepair, a contractor evaluated the flooring issue last week, and repairs are set to begin within the next couple of weeks. A total of six (6) residents were interviewed. Three (3) out of six (6) residents reported issues with the shower water pressure and accessibility into the bathtub due to mobility issues. Staff stated that in the past a plumber evaluated the water issues. It was determined that both this facility and the SNF next door have common plumbing pipes that are occasionally getting clogged.

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

NOTE: Civil penalties are being assessed for repeat violations within the last 12 months.

Exit interview was conducted with Interim Administrator Nelida Arlante and Administrative Assistant Sau Lee. 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: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230425105928

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: 05/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/05/2023 Section Cited CCR 87303(e)(6)	1 2 3 4 5 6 7	Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator shall submit written notification certifying that all resident bathrooms were inspected in order to determine the operating condition of all water fixtures in resident rooms, common bathrooms, and kitchen areas. Submit an updated LIC 610E Emergency and Disaster Plan.
	8 9 10 11 12 13 14	Based on observation and interviews conducted on April 23, 2023, room # 230's bathtub water fixtures could not be turned off. Security guard shut off the water supply without notifiying Administration staff and residents. Room #230's issue was repaired the same day.	8 9 10 11 12 13 14
Type B 05/05/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	Licensee shall submit all required Change of Administrator documents to CCL, and ensure the appointed Administrator is at the facility sufficient number of hours to permit adequate attention to the management and administration of the facility. Submit self-certification, written statement, and pending documents.
	8 9 10 11 12 13 14	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. On 3/31/23, incomplete Administrator change documents were submitted. The Interim Administrator appointed is not at the facility sufficient number of hours.	8 9 10 11 12 13 14	*Note a civil penalty was assessed.

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: 05/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230425105928

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: 05/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/05/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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 evidenced by:	1 2 3 4 5 6 7	Licensee shall ensure the facility is in good repair at all times, and areas in need of repair are addressed in a timely manner. Submit picture proof of corrections made to the Demenia unit flooring, resident room carpets, and needed door and wall repairs.
	8 9 10 11 12 13 14	Based on physical plant observation, the Dementia unit's laminate flooring is in disrepair, resident rooms have stained carpets, and there are room doors that need repair on the bottom half caused by wheelchairs; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	NOTE: If a POC extension is needed submi a written request prior to or by the due date.
	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: 05/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5