198602564-5-12-2021-28-AS-LHIS-C76U2E-20210924151144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 05/12/2021
Date Signed: 05/12/2021 05:35:05 PM

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
04/21/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210421093846

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
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Marina Galaviz, Resident Care Coordinator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Resident did not receive medications appropriately.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Noemi Galarza and Nune Maragaryan conducted a subsequent complaint investigation visit. Findings were delivered for the above allegation. LPAs met with Resident Care Coordinator Marina Galaviz, the purpose of the visit was explained.

The investigation consisted of: On 4/29/2021, no staff were available to assist with the visit. On today's date [5/12/2021] LPAs reviewed nine (9) centrally stored resident medication records. Resident (R1's) documents were obtained on 5/4/2021. A total of two (2) staff were interviewed. Resident (R1) was interviewed today. Medication errors were observed when reviewing residents (R2, R3, and R4) medication administration records; which included an audit of the medications.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210421093846

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: 05/12/2021

NARRATIVE

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Allegation: "Resident did not receive medications appropriately." Based on records review and interviews conducted the findings indicate resident (R1) was no administered medications as directed by physician. Resident moved in on 4/3/2021. The resident's medication list was emailed to facility staff prior to move-in date. On 4/3/2021, R1 brought medications in a weekly pill box. Facility staff did not verify medication list with physicians until April 16, 2021. Facility med-tech staff did not follow-up with pharmacy or physicians per facility protocols. During today's medication review errors were observed. Resident (R2's) Triamterene-HCTZ 37.5-25 mg medication was discontinued on 3/26/2021 per MAR (Medication Administration Record), but medications is still being dispensed. Resident (R3's) Betamethasone DP aug .05% medication listed on the MAR record was not found by staff. Resident (R4's) MAR indicated that medication Alendronate Sodium 70 mg is to be only administered once a week on Sundays. The MAR report had documentation errors. It stated that the medication was administered daily. Staff (S1) initials were observed.

Based on document review, and interviews conducted 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, Chapter 8, Article 08.

An exit interview was conducted with Resident Care Coordinator Marina Galaviz. A copy of the report an appeal rights were provided.

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210421093846

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: 05/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/14/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Licensee shall provide medication admininstration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.
	8 9 10 11 12 13 14	Based on records review facility staff did not verify medication list with R1's MD after moving in. Per Medication Administration Records (MAR) residents (R1-R4) were not administered medications as directed per physicians.	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: 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

LIC9099 (FAS) - (06/04)

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