Royal Vista Care Center, San Gabriel, CA: Nursing home

Overall1★☆☆☆☆

Inspections1★☆☆☆☆

Staffing3★★★☆☆

Quality2★★☆☆☆

Federal finesNoneon record

Inspection citations

18’23

43’24

7’25

34’26

Year

102 shown

Date	Severity	What inspectors found	Visit
Aug 28, 2026	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Aug 28, 2026	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Complaint
Aug 28, 2026	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Aug 28, 2026	D · potential	Make sure that a working call system is available in each resident's bathroom and bathing area.	Complaint
Jul 17, 2026	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Jul 17, 2026	E · potential	Provide and implement an infection prevention and control program.	Complaint
May 13, 2026	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Apr 29, 2026	E · potential	Provide and implement an infection prevention and control program.	Complaint
Feb 12, 2026	D · potential	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	Routine
Feb 12, 2026	D · potential	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Routine
Feb 12, 2026	E · potential	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	Routine
Feb 12, 2026	E · potential	PASARR screening for Mental disorders or Intellectual Disabilities	Routine
Feb 12, 2026	E · potential	Provide care and assistance to perform activities of daily living for any resident who is unable.	Routine
Feb 12, 2026	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Routine
Feb 12, 2026	D · potential	Assist a resident in gaining access to vision and hearing services.	Routine
Feb 12, 2026	E · potential	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Routine
Feb 12, 2026	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Feb 12, 2026	D · potential	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	Routine
Feb 12, 2026	D · potential	Provide safe and appropriate respiratory care for a resident when needed.	Routine
Feb 12, 2026	D · potential	Provide safe, appropriate pain management for a resident who requires such services.	Routine
Feb 12, 2026	D · potential	Provide safe, appropriate dialysis care/services for a resident who requires such services.	Routine
Feb 12, 2026	D · potential	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	Routine
Feb 12, 2026	E · potential	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Routine
Feb 12, 2026	E · potential	Ensure medication error rates are not 5 percent or greater.	Routine
Feb 12, 2026	E · potential	Ensure that residents are free from significant medication errors.	Routine
Feb 12, 2026	E · potential	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	Routine
Feb 12, 2026	D · potential	Provide routine and 24-hour emergency dental care for each resident.	Routine
Feb 12, 2026	E · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
Feb 12, 2026	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Routine
Feb 12, 2026	E · potential	Provide and implement an infection prevention and control program.	Routine
Feb 12, 2026	D · potential	Implement a program that monitors antibiotic use.	Routine
Feb 12, 2026	E · potential	Develop and implement policies and procedures for flu and pneumonia vaccinations.	Routine
Feb 12, 2026	E · potential	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	Routine
Feb 12, 2026	B · minimal	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	Routine
Mar 13, 2025	E · potential	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	Complaint
Mar 3, 2025	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Mar 3, 2025	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Mar 3, 2025	D · potential	Provide and implement an infection prevention and control program.	Complaint
Jan 29, 2025	G · harm	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Jan 10, 2025	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Jan 10, 2025	D · potential	Provide and implement an infection prevention and control program.	Complaint
Dec 18, 2024	E · potential	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Complaint
Dec 18, 2024	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Complaint
Nov 21, 2024	E · potential	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	Routine
Nov 21, 2024	D · potential	Ensure that residents are fully informed and understand their health status, care and treatments.	Routine
Nov 21, 2024	D · potential	Allow residents to self-administer drugs if determined clinically appropriate.	Routine
Nov 21, 2024	D · potential	Reasonably accommodate the needs and preferences of each resident.	Routine
Nov 21, 2024	D · potential	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	Routine
Nov 21, 2024	D · potential	Keep residents' personal and medical records private and confidential.	Routine
Nov 21, 2024	E · potential	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Routine
Nov 21, 2024	D · potential	PASARR screening for Mental disorders or Intellectual Disabilities	Routine
Nov 21, 2024	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Routine
Nov 21, 2024	E · potential	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	Routine
Nov 21, 2024	E · potential	Provide activities to meet all resident's needs.	Routine
Nov 21, 2024	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Routine
Nov 21, 2024	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Routine
Nov 21, 2024	D · potential	Provide enough food/fluids to maintain a resident's health.	Routine
Nov 21, 2024	D · potential	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	Routine
Nov 21, 2024	D · potential	Provide safe, appropriate pain management for a resident who requires such services.	Routine
Nov 21, 2024	B · minimal	Post nurse staffing information every day.	Routine
Nov 21, 2024	D · potential	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Routine
Nov 21, 2024	D · potential	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	Routine
Nov 21, 2024	E · potential	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	Routine
Nov 21, 2024	E · potential	Ensure medication error rates are not 5 percent or greater.	Routine
Nov 21, 2024	D · potential	Ensure that residents are free from significant medication errors.	Routine
Nov 21, 2024	E · potential	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	Routine
Nov 21, 2024	D · potential	Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	Routine
Nov 21, 2024	D · potential	Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	Routine
Nov 21, 2024	E · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
Nov 21, 2024	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Routine
Nov 21, 2024	E · potential	Provide and implement an infection prevention and control program.	Routine
Nov 21, 2024	B · minimal	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	Routine
Nov 21, 2024	D · potential	Make sure that a working call system is available in each resident's bathroom and bathing area.	Routine
Nov 21, 2024	E · potential	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	Routine
Oct 24, 2024	D · potential	Let each resident or the resident's legal representative access or purchase copies of all the resident's records.	Complaint
Oct 8, 2024	E · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Oct 2, 2024	E · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Complaint
Sep 25, 2024	D · potential	Keep residents' personal and medical records private and confidential.	Complaint
Sep 23, 2024	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Sep 23, 2024	E · potential	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	Complaint
Aug 5, 2024	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Feb 2, 2024	D · potential	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	Complaint
Feb 2, 2024	E · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Jan 4, 2024	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Dec 8, 2023	D · potential	Reasonably accommodate the needs and preferences of each resident.	Routine
Dec 8, 2023	E · potential	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	Routine
Dec 8, 2023	E · potential	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Routine
Dec 8, 2023	D · potential	Ensure each resident receives an accurate assessment.	Routine
Dec 8, 2023	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Routine
Dec 8, 2023	E · potential	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	Routine
Dec 8, 2023	E · potential	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Routine
Dec 8, 2023	E · potential	Ensure medication error rates are not 5 percent or greater.	Routine
Dec 8, 2023	E · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
Dec 8, 2023	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Routine
Dec 8, 2023	D · potential	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	Routine
Dec 8, 2023	F · potential	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	Routine
Dec 8, 2023	E · potential	Provide and implement an infection prevention and control program.	Routine
Dec 8, 2023	B · minimal	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	Routine
Dec 8, 2023	D · potential	Make sure that a working call system is available in each resident's bathroom and bathing area.	Routine
Dec 8, 2023	E · potential	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	Routine
Oct 12, 2023	E · potential	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Complaint
Oct 12, 2023	D · potential	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	Complaint

Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.

Questions to ask on a visit

Royal Vista Care Center
909 W. Santa Anita Ave, San Gabriel, CA 91776 · (626) 289-5365

Visit date: ____________ Spoke with: ______________________

How many nurses and aides work each shift, including nights and weekends?
How do you handle the most recent citations on your record?
Do you accept Medi-Cal if private funds run out?
Who will be the main contact for the family?
How do you prevent falls, pressure sores and infections?

Record on file

Certification: Medicare and Medi-Cal certified skilled nursing facility
Medicare number (CCN): 055105
Certified beds: 99
Legal owner: Royal Vista Care Center LLC
Part of: Ahmc Healthcare

Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.

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