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Inspection visit

Incident investigation

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

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an incident report submitted to the District Office on 1/22/2023. LPA met with Administrator Chia Demurjian. The purpose of today's visit is to check on the health & safety of residents in care and to issue a citation in regards to the neglect of care. On Sunday January 22, 2023 at 7:10 AM, registry caregiver staff (S1) took Dementia resident (R1) inappropriately dressed into the dining room for breakfast. Resident (R1) was sitting in it's wheelchair with briefs, and pants down around the thighs. Another registry caregiver staff (S2) on duty addressed the concern with S1, but the staff walked away and left the resident unattended. Approximately 10 minutes later staff (S1) returned and began feeding R1. Staff (S3) noticed that S1 was force feeding the resident and shoving food in it's mouth. When the feeding was completed, staff (S1) left to get a clean shirt for the resident. At that point, staff S2 observed that the resident still had food in it's mouth. Staff (S2) removed the food in the resident's mouth in order to prevent choking or food aspiration. Staff (S1) returned to put a shirt on the resident. Shortly after other staff noticed the resident had blood on it's elbow. Of note, the resident does not have teeth and does not wear dentures. The resident received first aid and Wellness Nurse sent registry staff (S1) home. Facility notified the registry staff agency, and has not worked at the facility since January 22, 2023, and staff in-services were provided to staff. The facility reported the incident to APS, Police, and Ombudsman. A deficiency was cited according to Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right 87468.1 Personal Rights of Residents in All Facilities. An 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 other 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 other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

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.