198602564-6-1-2023-28-AS-NGAA-CSE3SW-20230601183101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 06/01/2023
Date Signed: 06/01/2023 06:31:11 PM

Document Has Been Signed on 06/01/2023 06:31 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 GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	NELIDA ESTRELLA ARLANTE		FACILITY TYPE:	740
ADDRESS:	901 W SANTA ANITA ST		TELEPHONE:	(626) 289-8889
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91776
CAPACITY:	100	CENSUS: 52	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nelida Arlante, Administrator		TIME COMPLETED:	06:30 PM

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

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Nelida Arlante arrived shortly after. There are currently 52 elderly residents 60 years and older residing in the facility. Four (4) residents are receiving hospice care, and five (5) residents are bedridden.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:

A current Plan of Operation at the facility is incomplete; only the Dementia plan was reviewed.The Infection Control Plan has been added to the Plan.
The facility has a Dementia Waiver in place. A Hospice Waiver for 5 residents is approved.
A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.
A Surety Bond is in place. The facility handles resident monies.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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: 06/01/2023

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

Physical Plant/Environment Safety:

The facility has a Dementia unit. A hospice waiver for 5 residents is in place. Facility is a 3-story building consisting of 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, and 2 courtyard patio areas.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
On 1/24/2023, City of San Gabriel FIre Department conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational.
Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total of 7 rooms had water temperatures ranging from 126.5 - 131.7 Degrees Fahrenheit.
Dementia unit flooring is in disrepair. Contractor has been hired to make the repairs.

Staffing:

Sufficient staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator completed recertification education, but has not received an RCFE certificate from CCL. Proof that the training was submitted was provided.
Staff have criminal background clearance and training.
Seven (6 staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed.

****Narrative continues next page****

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: 06/01/2023

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

Resident Records/Incident Reports:

A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. ***A total of 2 Dementia residents had Physician Report's older than 12 months.
RCFE complaint poster and Personal rights were observed posted. The Incident report binder was reviewed.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar is posted.
The facility does not have an active Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Physician orders for modified diets are on file.
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

Five (5) centrally stored resident medications were reviewed; which contained 30-day supply of medications.
Medical and dental transportation is provided.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place. There is no evacuation chair at each stairway. Citation was issued.
The last quarterly emergency drill was conducted on 5/22/2023.
Records of resident Appraisal and Needs services plans are part of Emergency training.

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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: 06/01/2023

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

Residents with Special Health Needs:

Eight (8) residents are receiving home health services. Four (4) residents receive hospice care.
Postural support physician orders are on file.
Half and full bed rails for mobility assistance were observed in resident rooms.
Individual Service Plans and Appraisals are on file.
No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Nelida Arlante. 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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/01/2023 06:31 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(C)

Personal Accommodations and Services

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the majority of the rooms inspected had beds without mattress pads; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure that all resident beds have mattress pads. Submit a written plan of correction.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that annual assessments for Dementia two (2) Dementia residents are older than 1 year; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure all Dementia residents have annual medical assesssments. Submit proof that R3 & R4 have current annual assessments.

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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 06/01/2023 06:31 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that resident in room 218 had full bed rails and is not enrolled in hospice; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove the full rails from the resident's bed and obtain a half rail physician order. Submit proof of correction (picture) and a copy of the physician order.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the hot water temperature readings today a total of 7 rooms had hot water temperatures above 120 D; which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure the hot water temperature in all resident rooms meets Title 22 regulation at all times of the day. Submit a written statement of how the deficiency was corrected. Staff shall check the temperature of all resident rooms. If needed contract a plumber to fix the issue.

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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6