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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:16:16 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
03/21/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230321092912
FACILITY NAME:ROYAL VISTA SAN GABRIELFACILITY NUMBER:
198602564
ADMINISTRATOR:CHIA Y. DEMURJIANFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 48DATE:
03/24/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Elizabeth Contreras, Wellness NurseTIME COMPLETED:
03:42 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
Staff did not get consent from responsible party for resident to see a different doctor.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the able allegation. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Chia Demurjian is not available due to short term leave of absence.

The investigation consisted of the following: Medication Administration Records (MAR) and resident (R1's) file was reviewed. Resident (R1's) medications were reviewed. Documentation errors on MARs were noted. Staff (S1-S5) and residents (R1-R5) were interviewed. Resident (R1's) medication records were reviewed. The following documents pertaining to R1 were obtained: Identification and Emergency Information, Face Sheet, Physician Report, Medication Administration Records (Aug. 2022- March 2023), Physician orders Aug 2022- to present, LIC 500 Personnel Report, and resident roster.

See LIC 9099C for report continuation.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
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 4
Control Number 28-AS-20230321092912
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: 03/24/2023
NARRATIVE
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Allegation: Staff are mismanaging resident's medications. It is alleged the facility began giving resident (R1) the wrong prescription medication dosage of "Rexulti" medication in October 2022. For many years the resident has had in place a physician order for Rexulti 4 mg. The findings indicate that R1 was assessed by the facility's in-house Psychiatrist on 9/19/2021, and as a result the medication dosage was changed from 4mg to 3mg. According to staff interviews, in September 2022, the facility Administrator asked med-tech staff (S1) for a list of residents in need of Psychiatrist care. The med-tech reviewed R1's chart and noted there was no Psychiatrist listed on the form. Therefore, assumed the resident did not have a Psychiatrist in place and referred the resident to the in-house Psychiatrist. After the resident was assessed, a lower prescription dosage was ordered by the in-house doctor on October 11, 2022. The resident began taking 3mg of Rexulti until January 14, 2023. In addition, R1 was prescribed melatonin for sleep cycle regulation, but per family request it was discharged on November 18, 2022. A total of five (5) residents were interviewed; of which none had knowledge of medication mismanagement. During today's, medication review LPA observed errors in MAR's records. Staff acknowledged the documentation errors. All staff interviewed confirmed R1's medications orders were mismanaged due to incomplete file records and lack of interdisciplinary team care coordination. There is sufficient evidence to corroborate the allegation.

Allegation: Staff did not get consent from responsible party for resident to see a different doctor. It is alleged that facility staff changed resident (R1's) Psychiatrist without responsible party's consent. Which resulted in medication errors due to record review oversight. Per staff interviews, a "Change of Primary Physician" form is to be completed and signed by the resident's responsible party whenever a doctor change is made. However, Administration staff did not notify and communicate with R1's responsible party, and proceeded to change R1's Psychiatrist to their in-house new Psychiatrist. All staff interviews confirmed the change was made without getting consent.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D.

NOTE: Civil penalties are being assessed for repeat violations within the last 12 months.

Exit interview was conducted with Wellness Nurse Elizabeth Contreras. 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: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230321092912
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: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2023
Section Cited
CCR
87465(c)(2)
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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.
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Licensee shall submit a plan of action to correct this repeated violation. In addition, all med-tech staff shall receive in-service training by a nurse and/or pharmacy. Submit the plan by tomorrow, and provide proof of staff training by Tuesday 3/28/23.
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Based on records review, R1 had in place a physician order for Rexulti 4 mg and it got changed to 3mg on 10/11/22 by a different unathorized doctor. This poses an immediate health and safety risk to persons in care.
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Type B
03/27/2023
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities. Residents in residential care facilities for the elderly shall have personal rights which include.....8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Licensee shall submit a written plan of correction, and conduct in-service training to all staff responsible with care plan responsibilities.
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Based on record review, facility staff did not obtain R1's responsible party's consent to change doctor; which poses a potential health and safety risk to persons 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: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230321092912
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: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2023
Section Cited
CCR
87411(d)(4)
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Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by:
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Licensee shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedure. Submit plan of correction.
***Due to repeated medication errors it is advised the facility use an electronic Medication Administration Records system.
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Based on interviews and record review, med-tech staff and Administration staff did not do their due diligence in reviewing all medication records and physician orders. In addition, MAR documentation errors were observed during today's visit; which poses a potential health and safety risk to persons 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: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4