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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 07/27/2021
Date Signed: 07/28/2021 11:26:53 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 GABRIELFACILITY NUMBER:
198602564
ADMINISTRATOR:FUENTES, SUSANAFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY:100CENSUS: 48DATE:
07/27/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Francis Largoza, Corporate Nurse ConsultantTIME COMPLETED:
03:25 PM
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An Informal meeting was held via tele conference. The purpose of the meeting is to address staffing shortages and operational changes. Attendees present during the meeting were: Community Care Licensing, Assistant Program Administrator Claire Matsushita, Licensing Program Manager (LPM) Lisa Hicks, Licensing Program Analyst (LPA) Noemi Galarza, and Royal Vista San Gabriel LLC corporate staff, Board Representative Kevin Chen, Nurse Consultant Francis Largoza, and Nursing Home Administrator/Consultant Chia Demurjian.

On July 22, 2021, Community Care Licensing (CCL) obtained information there was staff shortages at the facility that resulted in lack of adequate care and supervision of residents. Only one (1) caregiver worked the PM shift. The caregiver provided care for residents in the Memory Care Unit, resulting in the 2nd and 3rd floor Assisted Living residents being unattended and without supervision. The following was discussed:
  • Staffing shortages and excess work hours of current staff. Recent staffing changes and corporate hiring plan to address staffing issues. Staffing update of Registered Dietician and new Administrator.
  • Staff responsibilities and duties. Clarification of facility security guard role and responsibilities. Corporate team acknowledged understanding of the seriousness of staffing shortages and health and safety issues.
  • Operational changes resulting in lack of facility leadership by an Administrator or designated substitute.
  • Medication management errors and staff training.
  • Lack of corporate oversight during COVID-19 pandemic and recent operational changes and issues during the past several months.
  • Future unannounced compliance case management visits.


CCL requested the following:
    1. Submit revised staffing plan and update Personnel Report list
    2. Submit updated License Administrative Organization form
    3 Special Incident Reporting
    4. Reassessment of all residents in order to determine facility care needs.
Exit interview conducted with Francis Largoza, Kevin Chen, and Chia Demurjian. A copy of the report was emailed to Nurse Consultant Francis Largoza.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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