198602564-5-13-2021-28-AS-NGAA-C2Y2KC-20210512172744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 05/12/2021
Date Signed: 05/13/2021 07:31:12 AM

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 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: 47	DATE:	05/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Marina Galaviz, Resident Care Coordinator		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Noemi Galarza and Nune Margaryan conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Resident Care Coordinator Marina Galaviz and explained the purpose of the visit. There are 47 residents ages 60 and above [7 ambulatory, 40 non-ambulatory, & 1 bedridden]. The facility has a Memory Care Unit. A hospice waiver for 5 residents is in place. Facility is a 3-story building consisting of 66 resident rooms, 2 activity rooms, TV room, Namaste room, dining room, laundry room, and 2 courtyard patio areas. Administrator certificate expires 12/11/2021. The following were observed/inspected: COVID-19 Infection Control Practices were observed in common areas, isolation rooms/wing areas, and resident rooms. COVID-19 infection control signs were observed in all common rooms, and hallways. However, the memory care unit isolation room area did not have signs posted outside the area. Facility has two (2) designated isolation areas. Ten (10) resident rooms were inspected. Nine (9) centrally stored resident medication records were reviewed. At 12:00 pm -1:15 pm medications were reviewed in both medication rooms [ assisted living area and memory care unit]. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Staff responsible for direct care and supervision were observed wearing masks. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Lunch dining service was observed. All residents were socially distanced according to local public health guidelines. Staff and resident files were not reviewed during today's visit.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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: 05/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation resident room 317 did not have hand washing soap in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care. In addition, hand sanitizer stations were not observed in the 2nd floor hallways.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Staff shall ensure there are always hand washing supplies in resident rooms at all times. Facility shall have hand sanitizer readily available in all facility floors for residents and visitors to access while walking down the hallways. Submit a written plan of correction explaining how it was resolved.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC809 (FAS) - (06/04)

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