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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601332
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:58:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230316130349
FACILITY NAME:ROYAL GARDEN GUEST HOMEFACILITY NUMBER:
374601332
ADMINISTRATOR:RODOLFO TABLADILLOFACILITY TYPE:
740
ADDRESS:39 G STREETTELEPHONE:
(619) 420-0830
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 4DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff Richard BaraynoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mismanaged a resident's medication
Staff discriminate against residents based on religion
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Richard Barayno.

Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources.

It was alleged staff mismanaged a resident's medication. During a visit at the facility, the LPA witnessed resident medication had been pre-poured to unlabeled containers, and medication per-poured for that date could not be immediately located. Interviews with an internal source revealed it was the staff’s protocol to pre-pour medication into a separate container, at least one day in advance. Interviews with internal and external sources revealed there had been occasions when a resident’s medication was not provided.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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 4
Control Number 08-AS-20230316130349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ROYAL GARDEN GUEST HOME
FACILITY NUMBER: 374601332
VISIT DATE: 06/22/2023
NARRATIVE
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It was alleged staff discriminated against residents based on religion. A source reported to the Department staff preferred a certain religion over another. An interview with internal sources revealed the staff had allowed religious groups to visit and residents to participate in religious services. It was also revealed staff had asked a resident to maintain his religion and not participate in religious rituals.

Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegations were Substantiated. The deficiencies were cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Caregiver Barayno and Edna Tabladillo, who was on the phone.

An exit interview was conducted with Caregiver Barayno, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230316130349

FACILITY NAME:ROYAL GARDEN GUEST HOMEFACILITY NUMBER:
374601332
ADMINISTRATOR:RODOLFO TABLADILLOFACILITY TYPE:
740
ADDRESS:39 G STREETTELEPHONE:
(619) 420-0830
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 4DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff RichardTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff forced resident to cut their beard
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Barayno. Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources.

It was alleged staff forced a resident to cut their beard. Interviews with internal and external sources did not reveal any concerns,nor evidence corroborating staff forced a resident to cut their beard.Interviews with internal sources revealed residents at the facility had not been forced to cut their beards. Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated. An exit interview was conducted with Caregiver Barayno, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.

Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20230316130349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROYAL GARDEN GUEST HOME
FACILITY NUMBER: 374601332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
87465(h)(3)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. This requirement was not met as evidenced by:
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Admisnistrator agreed to provide in service training to all staff on medication management, by July 15th 2023.

Administrator agreed to provide documentation of the training, by July 15th 2023.
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Based on interviews and observations, the licensee did not ensure each medicaitons container carried all the information specified, which posed a potential health, safety and personal rights risk to 4 of 4 person in care.
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Type B
06/22/2023
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (b) A licensed residential care facility for the elderly shall not discriminate against a person seeking admission or a resident based on the person's or resident's sex, race, color, religion, national origin, marital status, registered domestic partner status, ancestry, actual or perceived sexual orientation, or actual or perceived gender identity. This requirement was not met as evidenced by:
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Administrator agreed to provide staff in service training to all staff regarding personal rights, by July 15th 2023.

Administrator agreed to provide documentation, by July 15th 2023.
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Based on interviews, the licensee did ensure staff did not discriminate against a resident based on religion, which posed a potential health, safety, and personal rights risk to 1 of 4 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4