198602564-8-27-2024-28-AS-LHIS-D8RLF9-20240903084244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:50:47 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
03/22/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240322105813

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: 50	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Sarah Rafael, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff hit resident.
Staff restrained resident in care.
Staff handles residents in a rough manner.
Staff does not treat residents with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was explained to new Administrator Sarah Rafael.

The investigation consisted of the following: On 3/26/2024, a physical plant tour of the facility, record review, and interviews of staff (S3- S8) and residents (R1-R4) were conducted. Staff (S1) is presently suspended and staff (S2) was terminated March 24, 2024, therefore, were not interviewed. Resident (R1 & R2's) and staff (S1 & S2) file records were obtained. On 3/27/2024, staff (S1, S9, S10) were interviewed telephonically. During today's visit, record review was completed, residents (R5- R9) and staff (S11) were interviewed, a collateral visit to the San Gabriel Police Department was conducted.

NOTE: New Administrator began working at the facility on June 3, 2024. Licensee failed to notify CCL of Administrator change. Therefore, a CM visit was created.

***Report narrative continues next page.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240322105813

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: 08/27/2024

NARRATIVE

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Allegation: Staff hit resident. The complaint alleges that on 2/29/2024 four (4) elderly residents disclosed they were been hit "swatted" by caregiver staff (S1). On 3/26/2024, LPA interviewed with translation assistance four (4) Mandarin speaking residents (R1- R4). Three (3) out of the 4 residents allegedly hit denied the allegation. Residents (R1 & R2) were unable to recollect due to cognitive impairment due to Dementia diagnosis. A total of nine (9) residents were interviewed. Resident (R5) stated that caregiver (S1) slapped/hit their legs on numerous times during incontinence care if the resident commented or asked the staff a question. Another resident (R4) was not a victim of abuse, but overheard several residents on different occasions yell for help saying that staff hit them.

A total of 9 staff were interviewed. Staff (S1) denied hitting residents. S1 stated that R2 was taken to bathroom to bathe in the middle of the night because the resident had smeared feces on themselves, but the resident pushed away staff and began screaming "Don't hit me". S1 stated that in regards to R5, while providing incontinence care R5 complained of pain in the genitalia area and then the resident moved and their cell phone hit the resident in the head. Staff (S1) denied hitting the resident in the head. The majority of staff reported having no knowledge that S1 was physically abusing residents. However, former Administrator Nelida Arlante conducted an internal investigation, and discovered that staff (S1) hit residents (R2 & R5). In addition, another caregiver (S2) was found to have been physically abusive towards residents. On 3/24/2024, staff (S2) was terminated. LPA attempted to interview S2, but no response was received. Per record review, Administrator immediately suspended staff (S1) on 3/1/2024 and reported it to all required agencies. The San Gabriel Police Department opened an investigation of elder abuse. As of today, Administration staff have not officially terminated staff (S1) because the police department has not provided a copy of the report, but visited the facility last week to inform staff that they closed the investigation. LPA requested investigation findings report from the San Gabriel Police Department, however, a copy of the report has not been furnished. There is sufficient evidence to corroborate the allegation.

***Narrative continues next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240322105813

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: 08/27/2024

NARRATIVE

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Allegation: Staff restrained resident in care. Information obtained states that staff (S1) tied resident (R2) to their wheelchair with a blanket and told another staff not to untie the resident so that they do not put their hand in their incontinence diaper. A total of 9 residents were interviewed, of which none confirmed the allegation. The investigation revealed that resident (R2) is a Dementia resident whose room was located in the Assisted Living floor, and not the Memory Care Unit. The resident was incontinent and had behaviors such as, taking off their diaper and playing with bowel movements. According to staff interviews, R2 did not have any postural supports physician's orders, but was restrained in effort to prevent incontinence behaviors, and potential falls. Staff (S1) stated that the 2nd floor of the facility has a lot of residents that require total care, and only 2 night shift caregivers responsible for providing care incontinence care and other care as needed. Based on staff interviews conducted the findings indicate that staff (S2) found (R2) restrained to their wheelchair, after S1's night shift ended. Staff (S1) admitted that R2 was restrained because the resident played with their feces. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Staff handle residents in a rough manner. It is being alleged that staff (S1) handled resident (R5) harshly while providing incontinence care. A total of 9 residents were interviewed, of which 2 residents confirmed that staff (S1) was impatient and yelled at the residents while providing assistance, and often handled the residents very rough. A total of 9 staff were interviewed. Staff (S1) denied mishandling or mistreating the resident(s), and stated they assisted other staff fulfill their care assignments. Staff interviewed stated that the majority of staff treat residents kindly, but sometimes visible bruises were observed on the arms of some residents, which was then reported to supervisors. Based on staff interviews conducted, the findings indicate that staff (S1) handled residents (R1, R3, & R5) in a rough manner while providing incontinence and ADL care. Additionally, S2 was observed on surveillance lifting, shaking, and roughly sitting Memory Care resident (R10) down on their wheelchair. Based on interviews, record review, and photograph evidence it was discovered that staff (S1) has rough handled multiple residents as far back as December 2023. Therefore, there is sufficient evidence to corroborate the allegation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20240322105813

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: 08/27/2024

NARRATIVE

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Allegation: Staff do not treat residents with dignity and respect. Concerns were reported that residents were being yelled at and treated in a rude manner. Information obtained revealed that staff (S1 & S2) verbally abused residents by yelling and calling the residents derogatory/teasing names. Staff interviews revealed that 2 regular staff (S1 & S2) and 2 agency staff failed to treat the residents with dignity and respect because sometimes when staff heard the residents screaming or yelling they would simply close the door and ignore the residents. Administrator stated that staff (S2) was terminated on 3/24/2024, due to employee-to-employee altercation, and not mistreatment of residents. Three (3) out of 9 residents reported instances of disrespect. Resident (R3) stated that staff (S1) would yell and spray water in their face or bathe the resident at 1:00 AM. Resident (R5) stated that S1 threw a plush teddy bear at the residents' face and felt "treated like a prisoner". Resident (R8) reported that a staff pushed a resident's wheelchair inappropriately because the resident was shouting. The investigation revealed Administration staff had knowledge of staff misconduct, but the staff in question were not disciplined until after this complaint was filed.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited.

An exit interview was conducted and a copy of this report and appeal rights was provided to new facility Administrator Sarah Rafael.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240322105813

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: 08/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rihgts of Residents in All facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature............... ....sleeping, or elimination.	1 2 3 4 5 6 7	Administrator shall ensure that residents are free of punishment, humilation, initmidation, abuse..etc. Administrator will retrain staff on personal rights. Submit plan of correction by due date.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: The findings indicate that caregiver staff (S1) physically abused residents while providing assistance. S1 was suspended on 3/1/24, and is pending termination. This poses a potential health and safety risk ro persons in care.	8 9 10 11 12 13 14
Type B 09/06/2024 Section Cited CCR 87608(a)(1)	1 2 3 4 5 6 7	Postural Supports. Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.	1 2 3 4 5 6 7	Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87608. Written POC & proof of staff training must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews conducted, statements obtained corroborated with the allegation that S1 restrained R2 on their wheelchair by tying the reisdents hands in order to prevent the resident from putting their hands on diaper. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: 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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20240322105813

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: 08/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2024 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, ....:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	Administrator agreed to retrain all staff on regulation 87468.2, and submit proof of staff in-service training.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews conducted the findings indicate that S1 handled R1, R3, & R5 in a rough manner while providing incontinence and ADL care. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 09/06/2024 Section Cited CCR 87468.1(a)(1)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	A training regarding personal rights for residents will be provided to all staff prior to POC Due date. Executive Director Michael Forsgren will also provide training materials, agenda, and a log with staff signatures/initials proving they attened the training by POC due date.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on investigation findings staff (S1 & S2) were found to be treating residents in a disrespectful manner by yelling and ignoring the residents. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	Administrator agreed to retrain staff on regulation 87468.1, submit training log with staff signatures, and provide training materials by POC due date.

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: 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

LIC9099 (FAS) - (06/04)

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