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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:35:04 PM


Document Has Been Signed on 08/18/2023 04:35 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:NELIDA ESTRELLA ARLANTEFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 48DATE:
08/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Nelida Arlante, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on multiple AWOL incidents involving Memory Care resident(s). LPAs met with Administrator Nelida Arlante was explained the purpose of the visit.The purpose of today's visit is to check on the health & safety of residents in care.

On July 31,2023 at 6:15 pm, there was an electrical fire in the 1st floor/Memory Care Unit storage room located inside the break room. Fire department inspected the incident and stated the fire was a result of an electrical fire in a lower power outlet that had boxes nearby. Staff immediately evacuated all Memory Care residents to the front and back parking lots. No resident injuries were sustained.

As a result of the electrical fire, the 1st floor sprinkler system was triggered throughout the 1st floor and caused major water damage. The facility has scheduled repairs with a tentative completion date of 2 months. In the interim Memory Care residents have been relocated to the 2nd and 3rd floor.

On 8/8/2023 at 4:15 pm and 8/15/2023 8:00 pm Dementia resident (R1) AWOL. During the 8/15/2023, incident the resident fell and sustained a facial injury resulting in hospitalization.

During today's visit the following was conducted:


  • A physical plant tour of the damaged 1st floor Memory Care Unit was conducted.
  • There is a current COVID-19 outbreak in the 2nd floor. Infection control protocols are in place.

A deficiency was cited according to Title 22. See LIC 809D.

An exit interview was with Administrator Nelida Arlante. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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 08/18/2023 04:35 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: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
HSC
87411(a)

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Personnel Requirements-General. 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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Administrator agreed to submit a written plan addressing staff supervision, protocols, and staff scheduling.
Submit proof of staff in-service training regarding Dementia wandering behavior, methods of redirection, and resident care and supervision.
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On 8/8/23 & 8/15/2023 Dementia resident (R1) eloped out of the facility. During the 8/15/23 elopement the resident fell and sustained a facial injury resulting in hospitalization. Due to a recent fire Dementia residents are not in a locked perimeter. This poses an immediate safety risk to this residenst 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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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