198602564-3-26-2021-28-AS-MVAO-C5SQSK-20210811122540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 03/24/2021
Date Signed: 03/26/2021 09:14:13 AM

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
03/19/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210319125851

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: 48	DATE:	03/24/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Susana Fuentes, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility did not issue a refund to authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was explained telephonically to Med-Tech Ruby Ramos. Administrator Susana Fuentes was available later.

The investigation consisted of the following: Staff (S1- S5) were interviewed.The following documents were obtained: Resident (R1's) Identification and Emergency Information/Face Sheet, Admission Agreement/Addendum, house rules, Jan. 13, 2021 hospitalization incident report, death notification documentation, and death report. Documents requested and NOT obtained: Plan of Operation [Refund Section pages], proof of facility discharge, email correspondence re: personal belongings inventory list, proof of belongings pick-up by family, proof of corporate office refund request, and proof of processed refund. Administrator stated she will send signed reports by tomorrow 3/25/2021.

*** See LIC 9099C for continuation of report.

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: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

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-20210319125851

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: 03/24/2021

NARRATIVE

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Allegation: "Facility did not issue a refund to authorized representative." Based on interviews conducted and document review the findings indicate the facility failed to issue a issue a prorated refund of the rent paid for the month of January 2021, within 15 days after the personal property was removed. Resident (R1) died on January 26, 2021, and resident's authorized representative notified the facility the same day. On January 27, 2021 authorized representative emailed the facility an inventory list of R1's personal belongings. Authorized representative was not contacted by staff to schedule a pick-up date of belongings removal. Authorized representative called the facility to follow-up. February 8, 2021 was established as the removal/pick-up of R1's personal belongings; belongings were removed that date.

According to Administrator/staff (S1) authorized representative was issued a check "sometime early February 2021" that was sent via mail, but was never received by authorized representative. Facility did not mail the 1st issued check via certified mail. On March 10, 2021, authorized representative contacted the facility about non-receipt of refund check, and was told that another check would be re-issued an be ready for pick-up on March 11, 2021. On March 13, 2021, authorized representative went to pick-up the refund check, but was informed by staff (S3 & S4) that they did not have the refund check; and was instructed to return to the facility on a weekday. Staff (S1) stated staff (S2) was given instructions about refund check pick-up. However, refund check was received by facility staff until March 18, 2021. Then on March 18, 2021, Administrator gave instructions to staff (S5) to give authorized representative the refund check. Staff (S5) stated authorized representative did not pick-up the refund check on that date. Per interviews conducted, authorized representative was not notified by any staff that the check was ready to be picked up. As of today's date, the refund check in the amount of $208.90 has not been issued to authorized representative.

According to Title 22, Division 6, Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly, Article 06. Other Provisions: §1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code, Chapter 3.2, Article 06. See LIC 9099D.
****A telephonic exit interview was conducted with Administrator Susana Fuentes. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210319125851

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: 03/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; ...... A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees...., within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Administrator agreed to reimburse a refund amount of ($208.90). The refund amount was calculated by daily rate, and resident (R1's) death date of Jan. 26, 2021. Refund was owed for dates Jan-27, 2021 - Jan 31, 2021. ***Submit proof by POC due date that authorized representative received the refund check.
	8 9 10 11 12 13 14	Resident (R1) died on 1/26/2021, personal belongings were picked up on 2/8/2021. On 3/13/2021 authorized representative went to pick-up refund check, and did not receive it. Facility received the refund check on 3/18/2021. As of today, representative has not been issued the check; $208.90 is owed.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

LIC9099 (FAS) - (06/04)

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