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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:56:11 PM


Document Has Been Signed on 08/27/2024 04:56 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: 50DATE:
08/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Sarah Rafael, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza initiated a case management visit due to observations during complaint investigation control #: 28-AS-20240322105813 visit. The purpose of the visit was explained to Administrator Sarah Rafael.

Upon arrival to the facility Corporate staff Jamie Toy and Steven Shulman stated that the facility hired a new Administrator. LPA informed staff that Licensee has not notified CCL of changes.

Ms. Sarah Rafael began working at the facility on June 3, 2024. However, licensee did not notify CCL of change of Administrator and has not submitted required documents in order to process the change.

Per Title 22, Title 22, Division 6 Chapter 8 Article 07. Personnel Administrator Recertification Requirements. 87407 (k)(1) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated.

Deficiencies were cited. Exit interview was conducted with Sarah Rafael. 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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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 08/27/2024 04:56 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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87407(k)(1)

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Personnel Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office .....
This requirement was not met evidenced by:
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Licensee shall submit change of Administrator documents to CCL by POC due date.

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Based on observation, the facility has a new Administrator. Licensee failed to report changes to CCL within 30 days. Administrator Sarah Rafael was hired on 6/3/24. This 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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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