198602564-8-24-2023-28-AS-FFIS-CVN44H-20230913184622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:40:57 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
08/18/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230818093551

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: 47	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Nelida Estrella Arlante, administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner resulting in resident falling.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Nelida Estrella Arlante, administrator. LPA explained the purpose of today's visit regarding the above-mentioned allegation.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4) and attempted to interview staff#5 (S5); interviews residents from resident#1 (R1) to resident#5 (R5); reviewed resident records; and toured the facility. LPA obtained copies of staff and resident rosters; and resident#1/ staff files with relevant information.

In regard to allegation of “staff handled resident in a rough manner resulting in resident falling,” it was alleged that facility staff pulled resident through resident’s sleeve and resident fell. The investigation revealed the following: LPA interviewed residents, all five (5) residents interviewed could not corroborate the allegation. Three (3) out of four (4) staff interviewed denied the allegation. (-continued in LIC 9099C-)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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-20230818093551

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: 08/24/2023

NARRATIVE

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One (1) out of four (4) staff stated resident#1 (R1) was handled with rough manner resulting in falling. Per file reviews, staff training records showed facility provided proper in – service training to staff. Per video footage review, dated 8/15/23, staff#1 had handled resident#1 with rough manner resulting resident#1 fell. Therefore, staff had handled resident in a rough manner resulting in resident falling.

Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with Nelida, administrator. A hard copy of this report and appeal right were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230818093551

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: 08/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/29/2023 Section Cited CCR 87413(a)(2)	1 2 3 4 5 6 7	Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee agreed to review Title 22 Regulations, Section 87413 (a)(2) and submit a written plan detailing how administrator would ensure that staff provide care and supervision without physical or verbal abuse. Licensee would provide proper training to staff on physical abuse. POC due on 8/29/23.
	8 9 10 11 12 13 14	Per reviews of staff record, staff interview and video footage (dated 8/15/23), the administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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