<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602564
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:17:11 PM

Document Has Been Signed on 12/11/2023 04:17 PM - It Cannot Be Edited

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:NELIDA ESTRELLA ARLANTEFACILITY TYPE:
740
ADDRESS:901 W SANTA ANITA STTELEPHONE:
(626) 289-8889
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 100CENSUS: 47DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Elizabeth Contreras, Wellness Director TIME COMPLETED:
04:20 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 Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an incident report dated 12/6/2023, submitted via SOC 341 "Report of Suspected Dependent Adult/Elder Abuse". LPA met with Wellness Director Elizabeth Contreras. The purpose of today's visit is to check on the health & safety of residents in care and to obtain resident records.

According to SOC 341, the facility reported suspected physical abuse of a resident. It is alleged that on 12/5/2023, 91 year old resident (R1's) family reported to Administration staff that they observed bruising on resident's arm and hands. The resident told family that caregiver staff (S1) hit the resident. Administration staff performed a body check and discoloration of R1’s left hand, left arm, and yellowish areas on left upper chest were observed in R1’s body.

On 12/5/2023, Administration staff opened an investigation. According to report, staff (S1) stated that at approximately 2:40 PM, while showering the resident staff noticed bruising. On 12/5/2023, staff (S1) took the resident to the Wellness Department office. Resident (R1) was asked about the bruising, and allegedly denied being hit by staff (S1). The resident reported to staff that they fell. Resident (R1) was removed from staff (S1’s) care responsibilities pending investigation findings.

  • LPA reviewed and obtained resident (R1's) file documents. Staff (S1's) file was locked. Therefore records were not obtained. Staff were instructed to email S1's Personnel record, proof of training, and disciplinary reports if applicable.
  • LPA obtained a copy of incident report and SOC 341. NOTE: Law enforcement agency has not visited the facility as of yet.
  • LPA interviewed staff (S1 - S2) and attempted to interview Dementia resident (R1).

Administration staff were instructed to notify LPA once their investigation is complete and submit additional evidence if any to CCL. If warranted, LPA will return to the facility.

During today’s visit, there were no deficiencies cited.

Exit interview conducted and a copy of the report was given to Wellness Director Elizabeth Contreras.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1