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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/17/2025
Date Signed: 06/17/2025 02:18:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2025 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250613111812
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 122DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Priscilla Gaytan TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure resident was allowed to be readmitted to facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Administrator Priscilla Gaytan and discussed the purpose for todays visit.

Investigation consisted of: staff roster, resident roster, residents discharge papers, ID page, physicians reports, interviewed staff #1, and requested specific documents from resident 1 files, attempted to interview resident #1.
Investigation revealed:
Regarding allegation:Staff did not ensure resident was allowed to be readmitted to facility. LPA Wesley spoke to the Administrator Priscilla Gaytan and she informed me that the facility did take the resident back, They are located in the memory care unit, LPA Wesley and the Administrator walked to the memory care unit and LPA greeted the resident and asked the name. They said they are resident 1. LPA Wesley spoke to staff 1 and she said there must have been a misunderstanding, they took the resident
continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 2
Control Number 28-AS-20250613111812
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAN DIMAS RETIREMENT CENTER
FACILITY NUMBER: 191500609
VISIT DATE: 06/17/2025
NARRATIVE
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back and she was asking if they knew of a place that can assist the resident with a higher level of care, because of their aggressive behavior which can be a hazard for the staff and the other residents in care, and the resident is a fall risk, he can barely walk and he often falls.

Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A copy of this report was given to the Administrator Priscilla Gaytan.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2