198602564-6-30-2021-28-AS-RORN-CQ6VMD-20230322163322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 06/30/2021
Date Signed: 06/30/2021 03:01:31 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
06/28/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210628152714

FACILITY NAME:	ROYAL VISTA SAN GABRIEL		FACILITY NUMBER:	198602564
ADMINISTRATOR:	FUENTES, SUSANA		FACILITY TYPE:	740
ADDRESS:	901 W SANTA ANITA ST		TELEPHONE:	(626) 289-8889
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91776
CAPACITY:	100	CENSUS: 48	DATE:	06/30/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Marina Galaviz, Resident Care Coordinator		TIME COMPLETED:	03:12 PM

ALLEGATION(S):

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Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Resident Care Coordinator Marina Galaviz.

The investigation consisted of the following: At 10:40 am medication review was conducted. A total of four (4) resident medications were reviewed. Medication errors were observed for residents (R2-R4). Staff (S1 & S3) were interviewed and file documents were reviewed. Resident (R1's) file documents were obtained [Identification and Emergency Information, Physician Report, Admission Agreement, resident roster, Medication Administration Records, med-tech job description, and LIC 500 Personnel Report.

See LIC 9099C for report continuation.

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: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20210628152714

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: 06/30/2021

NARRATIVE

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Allegation: Staff mismanaged resident's medication. Based on observations made during record review and interviews conducted the findings indicate that on June 25, 2021 resident (R1) was not administered medications as directed. On 6/23/2021 and 6/24/2021 resident (R1) experienced vomiting and pain. Resident (R1's) doctor sent a physician order for two medications Cirpo and Zofram to the pharmacy. In addition, the facility failed to obtain R1’s aspirin 81 mg medication refill in advance. The aspirin medication was not administered on June 23 & 24. Facility med-tech staff stated the refills were received until June 25, 2021 at approximately 7:00 pm. However, the facility security guard received the medications. Med-tech staff (S2) did not ask security guard if R1's medications were received. Facility med-tech staff did not administer the medications to resident (R1) until the next day when med-staff (S4) found R1's medications in between 2 medication bins. NOTE: It is not the third party security guard's responsibility to receive or handle resident medications.

Staff stated resident (R1's) medications were not refilled on time because the resident's doctor did send the physician order to the pharmacy in a timely manner. It was also revealed that due to facility staff shortages it is sometimes not possible to follow-up with doctor offices or pharmacies in order to check the status of the refills. During today's medication review a total of four (4) medication administration records were reviewed. Medication errors were observed for residents (R2-R4). Resident (R2) was missing 3 medications and two medications were observed but not listed on record. Per staff, the resident's medications have not been refilled because MD requested to see the resident prior to authorizing refills. Resident (R2) was missing one (1) medication and also had 6 medications pre-poured 3 days in advance. Resident (R3's) Clonidine .1 mg medication refill has not been received. Staff have not checked the status on the medication delivery.

The facility does not have in place an electronic medication administration records system.

Based on document review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 08. ***CIVIL PENALTY WAS ASSESSED

An exit interview was conducted with Resident Care Coordinator Marina Galaviz and corporate staff Consultant Chia Demurjian and corporate witness Brenda Nicolas. A copy of the report an appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210628152714

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: 06/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/01/2021 Section Cited CCR 87465)(c)(2)	1 2 3 4 5 6 7	87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Licensee shall submit a copy of written medication administration protocols, and a plan that addresses the medications errors. In addition, all med-tech staff shall obtain medication training from a pharmacy. Submit proof of corrections by tomorrow. ***CIVIL PENALTIES WERE ASSESSED
	8 9 10 11 12 13 14	Based on records review the facility failed to obtain medication refills for resident (R1) and not administered medications as directed until June 26, 2021. During today's visit, medication errors were observed for residents (R2-R4). This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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