191500609-7-21-2021-28-AS-WSHO-C6X2WG-20210916174531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:11:11 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
06/11/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611104456

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 157	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Insufficient staffing to meet residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Priscilla Gaytan and explain the reason for the visit. The initial complaint visit was conducted on 6/19/21.

The investigation consisted of the following: LPA obtained the resident and staff roster, shower schedule and staff schedule. During the initial visit Interviews were conducted with 5 residents and 6 staff. Facility was toured and intercom system was tested. On 7/2/21, Interviews were conducted with 9 residents and 2 staff. On 7/16/21, 2 residents and 7 staff were interviewed. 1 additional staff was interviewed today. Facility was also toured including first floor, second floor and garden area.

The investigation revealed the following: It's alleged there is insufficient staffing to meet the residents needs. 12 out of the 16 residents interviewed reported that the facility is short staffed.
Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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 5

Control Number 28-AS-20210611104456

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: 07/21/2021

NARRATIVE

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5 residents reported they have missed as needed medication or pain medication or the medication has been delivered to residents late. Residents reported waiting 1 to 2 hours sometimes to receive the medication. Other residents reported pushing the call system in their room and waiting sometimes an hour for staff to respond.

Staff members interviewed included Licensed Vocational Nurses (LVNs), Med Techs., caregivers, kitchen staff, maintenance and housekeeping. 8 out of the 16 staff interviewed reported the facility is short staffed. It was reported the facility is short Med Techs, housekeepers, maintenance and kitchen staff. Staff report this has caused delays in meeting residents needs such as but not limited to medication management, residents not receiving required treatments, resident room cleaning, responding to resident call lights, maintenance of the building and kitchen staff that are not cooks having to cook for residents. Many staff reported often working overtime and working double shifts multiple times a week. This was described as "dangerous" because it can cause Med Techs and other staff to make a mistake if they are over worked.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210611104456

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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required....	1 2 3 4 5 6 7	Administrator is in the process of interviewing staff. Administrator indicated new staff have been hired and facility also uses the registry. Facility will submit staffing plan by tomorrow.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: 12 out of the 16 residents interviewed reported that the facility is short staffed. 5 residents reported they have missed medication or it's been late. Residents reported waiting an hour for staff to respond to call system. 8 out of the 16 staff interviewed reported facility is short staffed and has caused delay in resident care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
06/11/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611104456

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 157	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident suffered an unwitnessed fall and was not found until hours later.
Facility intercoms are in disrepair.
Resident(s) bathing needs are not being met.
Administrator is not communicating with the resident representative to discuss the resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Priscilla Gaytan and explain the reason for the visit. The initial complaint visit was conducted on 6/19/21.

The investigation consisted of the following: LPA obtained the resident and staff roster, shower schedule and staff schedule. During the initial visit Interviews were conducted with 5 residents and 6 staff. Facility was toured and intercom system was tested. On 7/2/21, Interviews were conducted with 9 residents and 2 staff. On 7/16/21, 2 residents and 7 staff were interviewed. 1 additional staff was interviewed today. Facility was also toured again including first floor, second floor and garden area.

The investigation revealed the following: Allegation: Resident suffered an unwitnessed fall and was not found until hours later. Residents interviewed did not support the allegation. Residents denied falling and staff not responding. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210611104456

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: 07/21/2021

NARRATIVE

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Staff interviewed denied the allegation. Staff have no knowledge of a resident laying on the floor for a long time after a fall. There were no witnesses to the alleged incident. Therefore, this allegation is unsubstantiated.

Allegation: Facility intercoms are in disrepair. Intercom system was tested on 6/19/21 and 7/2/21. The intercom was observed to be operating properly. Residents interviewed indicated the intercom system works, but the issue is staff do not always respond promptly. Staff interviewed indicated there is no issue with the intercom system. Maintenance staff indicated the intercom system has not been a problem. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Resident(s) bathing needs are not being met. Residents interviewed did not corroborate the allegation. Residents did not report any issues with the bathing schedule. Staff interviewed deny the allegation. Staff indicated there are sufficient bath aides to assist with bathing residents. Also many residents do not need assistance with showering. Based on information obtained, the allegation is unsubstantiated.

Allegation: Administrator is not communicating with the resident representative to discuss the resident's needs. Residents interviewed did not corroborate the allegation. Residents have not experienced this issue. Staff interviewed had no knowledge of this issue. Staff has not received any complaints regarding this allegation. Based on information obtained, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

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