Resident rights
Cited in 2 reports, with 4 deficiencies in total.
ROYAL VISTA SAN GABRIEL
901 W SANTA ANITA ST, San Gabriel CA 91776
100 bedsLatest official report Jul 21, 2026Licensed
Additional info
- Telephone
- (626) 289-8889
- Licensee
- ROYAL VISTA SAN GABRIEL LLC
- Administrator
- SARAH RAFAEL
- Contact
- SARAH RAFAEL
- License first date
- May 23, 2018
- License effective date
- May 23, 2018
- District office
- MONTEREY PARK ASC · (323) 980-4934
- Regional office
- 28
- Clients served
- 935 - ELDERLY
Summary
The available records show 12 Type A and 25 Type B deficiencies for this facility.
- Most recent inspection
- Apr 9, 2026
- Most recent deficiency
- Apr 9, 2026
1 later report, on Jul 21, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 212 Los Angeles County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 27 reports for this facility: 15 inspections, 12 complaint investigations, and 0 licensing or administrative records.
Those records contain 12 Type A and 25 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 15
- Recorded deficiencies
- 37
- Type A deficiencies
- 12
- Type B deficiencies
- 25
- Substantiated complaints
- 9
- Repeated topics
- 4
More than the typical 7
1 in the last 12 months
Well above the typical 8
3 in the last 12 months
Well above the typical 3
0 in the last 12 months
Well above the typical 5
3 in the last 12 months
Well above the typical 3
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Food service
Cited in 2 reports, with 3 deficiencies in total.
Facility condition and maintenance
Cited in 2 reports, with 2 deficiencies in total.
Health conditions and treatments
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations4 substantiated · 0 unsubstantiated · 0 unfounded · 4 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(3)
- Regulation authority
- CCR
What the official deficiency says
Personal Rihgts of Residents in All facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature............... ....sleeping, or elimination. This requirement was not met evidenced by: The findings indicate that caregiver staff (S1) physically abused residents while providing assistance. S1 was suspended on 3/1/24, and is pending termination. This poses a potential health and safety risk ro persons in care.
Official plan of correction
Administrator shall ensure that residents are free of punishment, humilation, initmidation, abuse..etc. Administrator will retrain staff on personal rights. Submit plan of correction by due date.
Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 6, 2024
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Postural Supports. Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by: Based on interviews conducted, statements obtained corroborated with the allegation that S1 restrained R2 on their wheelchair by tying the reisdents hands in order to prevent the resident from putting their hands on diaper. This poses a potential health and safety risk to persons in care.
Official plan of correction
Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87608. Written POC & proof of staff training must be submitted to CCL by the POC due date.
Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 6, 2024
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.2(a)(8)
- Regulation authority
- CCR
What the official deficiency says
Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, ....:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met evidenced by: Based on interviews conducted the findings indicate that S1 handled R1, R3, & R5 in a rough manner while providing incontinence and ADL care. This poses a potential health and safety risk to persons in care.
Official plan of correction
Administrator agreed to retrain all staff on regulation 87468.2, and submit proof of staff in-service training.
Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 6, 2024
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(1)(3)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) 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. This requirement was not met evidenced by: Based on investigation findings staff (S1 & S2) were found to be treating residents in a disrespectful manner by yelling and ignoring the residents. This poses a potential health and safety risk to persons in care.
Official plan of correction
A training regarding personal rights for residents will be provided to all staff prior to POC Due date. Executive Director Michael Forsgren will also provide training materials, agenda, and a log with staff signatures/initials proving they attened the training by POC due date. Administrator agreed to retrain staff on regulation 87468.1, submit training log with staff signatures, and provide training materials by POC due date.
Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 6, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(8)
- Regulation authority
- CCR
What the official deficiency says
Additional Personal Rights of Residents in Privately Operated Facilities: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met evidenced by: Based on record review and interviews conducted, the findings indicate that S1 made unauthorized charges totaling approximately $800.00 by using R1's bank card/PIN for online purchases that were never received by R1, and charging concert tickets on R4's card. This poses an immediate and health and safety risk to persons in care.
Official plan of correction
Facility shall submit proof of: 1. Written POC that includes the job description of staff that are responsible for handling resident's money and accessing confidential credit card information. 2. Proof of staff retraining on facility policy against taking money, bank cards/PINs from residents and regulation 87468.2.
Deadline recorded: Nov 20, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 20, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87413(a)(2)
- Regulation authority
- CCR
What the official deficiency says
Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met by evidence of: Per reviews of staff record, staff interview and video footage (dated 8/15/23), the administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
Licensee agreed to review Title 22 Regulations, Section 87413 (a)(2) and submit a written plan detailing how administrator would ensure that staff provide care and supervision without physical or verbal abuse. Licensee would provide proper training to staff on physical abuse. POC due on 8/29/23.
Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 29, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(8)
- Regulation authority
- CCR
What the official deficiency says
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 have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based on record review and interviews conducted staff did not notify R1's responsible party of 911 incident (4/25/23) and bill received pertaining to the incident; which poses a potential health and safety risks to persons in care.
Official plan of correction
Administrator agreed to provide in-service training regarding 87468.1, and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.
Deadline recorded: Jul 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 3, 2023
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... Based on record review and interviews conducted, staff failed to notify R1's responsible party and CCL within 7 days of the incident; which poses a potential health and safety risk to persons in care.
Official plan of correction
Administrator agreed to conduct in service training with staff. Send a copy of the inservice training log sheet. Note: A copy of the incident report was provided today and faxed to CCL on 6/2/2023.
Deadline recorded: Jun 26, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 26, 2023
Correction not verified in available records
Complaint
Allegations3 substantiated · 0 unsubstantiated · 0 unfounded · 3 cited
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(6)
- Regulation authority
- CCR
What the official deficiency says
Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met evidenced by: Based on observation and interviews conducted on April 23, 2023, room # 230's bathtub water fixtures could not be turned off. Security guard shut off the water supply without notifiying Administration staff and residents. Room #230's issue was repaired the same day.
Official plan of correction
Administrator shall submit written notification certifying that all resident bathrooms were inspected in order to determine the operating condition of all water fixtures in resident rooms, common bathrooms, and kitchen areas. Submit an updated LIC 610E Emergency and Disaster Plan.
Deadline recorded: May 5, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 5, 2023
Correction not verified in available records
Administrator qualificationsType B
- Official classification
- Type B
- Official code
- 87405(a)
- Regulation authority
- CCR
What the official deficiency says
Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. On 3/31/23, incomplete Administrator change documents were submitted. The Interim Administrator appointed is not at the facility sufficient number of hours.
Official plan of correction
Licensee shall submit all required Change of Administrator documents to CCL, and ensure the appointed Administrator is at the facility sufficient number of hours to permit adequate attention to the management and administration of the facility. Submit self-certification, written statement, and pending documents. *Note a civil penalty was assessed.
Deadline recorded: May 5, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 5, 2023
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met evidenced by: Based on physical plant observation, the Dementia unit's laminate flooring is in disrepair, resident rooms have stained carpets, and there are room doors that need repair on the bottom half caused by wheelchairs; which poses a potential health and safety risk to persons in care.
Official plan of correction
Licensee shall ensure the facility is in good repair at all times, and areas in need of repair are addressed in a timely manner. Submit picture proof of corrections made to the Demenia unit flooring, resident room carpets, and needed door and wall repairs. NOTE: If a POC extension is needed submi a written request prior to or by the due date.
Deadline recorded: Jun 5, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 5, 2023
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 3 cited
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(2)
- Regulation authority
- CCR
What the official deficiency says
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, R1 had in place a physician order for Rexulti 4 mg and it got changed to 3mg on 10/11/22 by a different unathorized doctor. This poses an immediate health and safety risk to persons in care.
Official plan of correction
Licensee shall submit a plan of action to correct this repeated violation. In addition, all med-tech staff shall receive in-service training by a nurse and/or pharmacy. Submit the plan by tomorrow, and provide proof of staff training by Tuesday 3/28/23.
Deadline recorded: Mar 25, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 25, 2023
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(8)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities. Residents in residential care facilities for the elderly shall have personal rights which include.....8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based on record review, facility staff did not obtain R1's responsible party's consent to change doctor; which poses a potential health and safety risk to persons in care.
Official plan of correction
Licensee shall submit a written plan of correction, and conduct in-service training to all staff responsible with care plan responsibilities.
Deadline recorded: Mar 27, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 27, 2023
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)(4)
- Regulation authority
- CCR
What the official deficiency says
Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by: Based on interviews and record review, med-tech staff and Administration staff did not do their due diligence in reviewing all medication records and physician orders. In addition, MAR documentation errors were observed during today's visit; which poses a potential health and safety risk to persons in care.
Official plan of correction
Licensee shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedure. Submit plan of correction. ***Due to repeated medication errors it is advised the facility use an electronic Medication Administration Records system.
Deadline recorded: Mar 25, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 25, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Administrator agreed to provide staff training to all med-tech staff by POC due date. Submit proof by POC due date. If an extension is needed submit by POC due date.
Deadline recorded: Jan 26, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 26, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.269(a)(21)
- Regulation authority
- HSC
What the official deficiency says
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.
Official plan of correction
Administrator agreed submit a written plan of correction addressing resident records, enumerated rights; severability, and facility procedures regarding resident records request. Submit by POC due date.
Deadline recorded: Jan 30, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 30, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement was not met evidenced by: Based on record review, R1's Medication Administration Record showed evidence of no medication administration beginning March 1, 2022, due to non-payment. This poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
Administrator shall obtain R1's medications immediately (no later than 24 hours) from the pharmacy. In addition, all med-tech staff shall be trained in their job responsibilities, and medication administration procedures. Submit proof of correction by tomorrow.
Deadline recorded: Mar 5, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 5, 2022
Correction not verified in available records
Complaint
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology