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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 11/17/2020
Date Signed: 11/17/2020 03:16:00 PM

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:FUENTES, SUSANAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 55DATE:
11/17/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Susana Fuentes, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza initiated a Case Management- Deficiencies visit due to the fact that facility Administrator failed to provide Community Care Licensing requested records pertaining to resident (R1)- complaint # 28-AS-20201109094754. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Susana Fuentes.

On 11/17/2020, LPA initiated a new complaint investigation pertaining to resident (R1). A list of documents needed for the investigation was emailed to Administrator at 9:26 am. Administrator stated that she contacted corporate staff Paul Hensler to obtain permission/direction regarding LPAs request. Administrator stated the corporate legal team is reviewing LPAs request. As of the close of this report time none of the documents requested were received.

Per Title 22, Division 6, Chapter 8, Article 09. Resident Records - 87506 (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours....... Facility Administrator failed to provide requested documents. Therefore, a citation is being issued.
See LIC 809D for deficiency cited.

A telephonic exit interview was conducted with the Administrator Susana Fuentes. A hard copy of the report, and Appeal Rights was emailed. Staff was instructed to sign the LIC 809/809D report pages and return to LPA.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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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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: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2020
Section Cited

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87506(d) Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours......

This requirement was not met by evidence of:
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On 11/17/2020, LPA requested resident (R1's) documents pertaining to complaint control # 28-AS-20201109094754. A list of documents needed was emailed to Administrator at 9:26 am. As of the time of this report the documents had not been received. Administrator stated the facility corporate legal team is reviewing document request, and she cannot furnish documents until permission is received.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2020
LIC809 (FAS) - (06/04)
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