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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/16/2020
Date Signed: 12/16/2020 03:30:55 PM



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
11/13/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201113153754
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:FERNANDA KEYFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 184DATE:
12/16/2020
UNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Fern Key, AdministratorTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff mishandles resident's medication
INVESTIGATION FINDINGS:
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*This is a corrected version of report dated 12/3/2020. The purpose of this report is to add the deficiencies page*
Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with administrator, Fern Key The initial tele-visit was conducted on 11/20/20. Staff #1 (S1) and administrator were interviewed at that time.

The investigation consisted of the following: LPA requested and obtained copies of Resident #1’s (R1's) Medication Administration Record (MAR) and staff schedule. Interviews were conducted with 3 staff including the administrator. R1 was also interviewed.

The investigation revealed the following: Administrator and Staff #2 (S2) confirmed an incident occurred with R1’s medication. S2 stated that on 11/8/20 S2 was setting up the medication and handed another staff member R1’s medication. The other staff member walked the medication to R1’s room and both R1 and the other staff member realized there was 1 pill that did not belong to R1. Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
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 3
Control Number 28-AS-20201113153754
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: 12/16/2020
NARRATIVE
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S2 realized the pill belonged to another resident with a similar name. S2 stated that the medication for the residents with a similar name have been placed on separate medication carts to avoid confusion in the future. R1 was interviewed and confirmed the incident occurred as well.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Fern Key and a hard copy was provided via email for signature along with appeal rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20201113153754
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2020
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administrator indicated that staff will be trained on medication procedures. Also, staff reported making the mistake because R1 has a similar name to another resident. Therefore, staff have separated both residents' medication into different medication carts to avoid confusion.
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This deficiency was evidenced by the following: Interviews confirm R1 was presented with the wrong medication by staff. Both staff and R1 realized there was 1 pill that did not belong to R1. R1 did not ingest the pill.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3