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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602564
Report Date: 10/20/2021
Date Signed: 10/20/2021 09:37:59 AM

Unsubstantiated


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
03/11/2020 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200311103919
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: 49DATE:
10/20/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:REGINA AGUILAR-GUEVARATIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Facility staff is falsifying documents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint investigation about the above allegation and deliver the finding. LPA met with Administrator, Regina Aguilar-Guevara and explained the reason of the visit.

The investigation consisted of the following: On 3/23/20, LPA Irra conducted the initial 10 days visit and LPA conducted a telephone interview with the prior administrator and requested copies of: resident and staff rosters (note: Facility Administrator indicated there are no LVNs nor RNs working at this facility). LPA Irra also obtained copies of the Job Descriptions/Duties for caregivers and med techs via email. On 09/28/2021, LPA Wong conducted a follow up visit and interviewed two (2) staff (S1-S2) and three residents (R1-R3), reviewed four residents' record and requested the four previous employee job application. On today's date, LPA interviewed one additional resident (R4).

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20200311103919
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: 10/20/2021
NARRATIVE
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The investigation revealed of the following: Allegation: “Facility staff is falsifying documents.” LPA interviewed four residents, and all denied the allegation and reported they are not aware of anything about staff falsified documents or they have no idea what is it about.. LPA interviewed staff and they all denied, and they never heard any staff falsified documents in the facility and they had no knowledge about that. LPA also interviewed the Prior and current administrator both reported Med-Tech can only pass the medication and cannot sign anything on behalf of any licensed staff or residents.

Based on the record review and interviews conducted, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal right was provided to Administrator Regina Aguilar-Guevara.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2