198602564-6-26-2023-28-AS-RORN-CTFLKH-20230705084934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 06/26/2023
Date Signed: 06/26/2023 01:10:28 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
05/30/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230530124614

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: 53	DATE:	06/26/2023
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Nelida Arlante		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff do not notify resident's responsible party of incidents.

INVESTIGATION FINDINGS:

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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 Nelida Arlante.

The investigation consisted of the following: On 6/1/2023, a physical plant tour of the facility, staff (S1- S3). and resident (R1) were interviewed. Resident (R1's) file documents [Face Sheet, bill (5/4/2023), Physician's report, Resident Appraisal, Appraisal Needs/Services Plan, LIC 500 Personnel Report, and roster were reviewed and obtained. During today's visit, incident report dated (4/25/2023) was provided. LPA interviewed four (4) responsible parties, staff (S4) and residents (R2-R4).

*** report narrative on 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: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

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-20230530124614

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: 06/26/2023

NARRATIVE

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Allegation: Staff do not notify resident's responsible party of incidents. It is alleged that on April 25, 2023 at approximately 2:30 PM, emergency medical personnel responded to a 911 phone call pertaining to resident (R1), but facility staff failed to inform R1's authorized representative of the incident because they felt that the incident was not severe enough. The resident's responsible party learned about an outstanding Emergency Medical Service bill from R1 and not facility staff. According to staff interviews, medical personnel deemed the incident a non-medical emergency and the resident was not transported to a hospital. Resident (R1) informed staff of the bill received, but staff did not notify R1's responsible party until two (2) weeks later. Resident (R1) was interviewed, but due to cognitive impairment the resident was not able to provide details related to the aforementioned incidents.

Administrative staff interviews revealed that R1's responsible party was not notified of the April 25, 2023 incident or the bill received. Staff (S2)/Administrator Assistant stated staff deemed the incident a false alarm since emergency personnel stated there was no need for medical treatment and did not report the incident to responsible party and Community Care Licensing. In regards to the bill, staff stated that facility staff tried handling the bill charges without notifying R1's responsible party. Staff contacted the fire department to try to get the bill waived but were not successful. Staff also contacted Medi-Cal regarding the outstanding bill. LPA called four (4) responsible parties; of which two (2) stated that in the past the facility has failed to notify them of incidents. A total of four (4) residents were interviewed. They did not report notification issues. However, pertaining to resident (R1's) incident (4/25/2023) and bill (5/4/2023) the facility failed to follow policy and procedure regarding incident notification.

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. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D.

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: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230530124614

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: 06/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/03/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.	1 2 3 4 5 6 7	Administrator agreed to provide in-service training regarding 87468.1, and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.
	8 9 10 11 12 13 14	Based on record review and interviews conducted staff did not notify R1's responsible party of 911 incident (4/25/23) and bill received pertaining to the incident; which poses a potential health and safety risks to persons in care.	8 9 10 11 12 13 14
Type B 06/26/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.....	1 2 3 4 5 6 7	Administrator agreed to conduct in service training with staff. Send a copy of the inservice training log sheet. Note: A copy of the incident report was provided today and faxed to CCL on 6/2/2023.
	8 9 10 11 12 13 14	Based on record review and interviews conducted, staff failed to notify R1's responsible party and CCL within 7 days of the incident; which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: 06/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023

LIC9099 (FAS) - (06/04)

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