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Inspection visit

complaint

ROYAL VISTA SAN GABRIELLicense 1986025641 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Allegation: Facility is not properly managing resident's medication. It is alleged that on January 22, 2023 at 2:00 PM, resident (R1) received resident (R2's) medication in error. Resident (R1) received all it's PM medications, and was given one (1) extra medication Velphoro 500 mg medication that belonged to resident (R2). The medication error was brought to the attention of the PM med-tech staff on duty (S7) on duty. Staff (S7) apologized and stated the medications were prepared by the previous day's PM med-tech staff (S1). A total of four (4) med-techs and two (2) administration staff were interviewed. Staff (S1) confirmed that it prepared/placed the resident's medications in small plastic cups the day prior, but denied making the medication error. Staff (S1) stated that it is unlikely that R2's Velphoro medication was placed in R1's medication cup because the medication is a large brown pill that looks different than all others. However, S1 stated that cups were rearranged by alphabetical order; which may have caused the error. A total of six (6) residents were interviewed. One (1) out six (6) residents confirmed the allegation. Resident (R1) stated that med-tech staff (S7) gave the resident another resident's medication. During today's visit, LPA reviewed a total of six (6) resident's medications and found no errors. Based on record review and a picture obtained of the medication that was administered in error there is sufficient evidence to corroborate the allegation. Based on observation, record 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. See LIC 9099D. Exit interview was conducted with Administrator Chia Demurjian. A copy of the report and appeal rights were issued.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.1(a)(3)Type A

    Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. Based on interviews conducted and document review, registry staff (S1) abused resident (R1) by not dressing the resident appropriately when taking it to the dining room, and force feeding the Dementia resident without regard to choking or apiration. This poses an immediate health and safety risk to persons in care.

  • 1569.269(a)(21)Type B

    Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met evidenced by: Based on record review, the facility received a formal medical records request on 10/22/2020, and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.

  • 87465)(c)(2)Type A

    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. Based on records review, on Jan. 22, 2023 med-tech staff gave resident (R1) resident (R2's) Velphoro 500 mg medication in error. R1 immediately reported the error, and the medication was not taken. This poses an immediate health and safety risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 26, 2023 inspection of ROYAL VISTA SAN GABRIEL?

This was a complaint inspection of ROYAL VISTA SAN GABRIEL on January 26, 2023. 1 citation were issued: 1 Type A (serious).

Were any citations issued to ROYAL VISTA SAN GABRIEL on January 26, 2023?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have ..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.