<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/04/2021
Date Signed: 06/04/2021 03:35:31 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
04/14/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210414142230
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: 159DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Priscilla Gaytan, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not administer residents’ medication as instructed by a physician.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with new administrator, Priscilla Gaytan and explained the reason for the visit. The initial complaint visit was conducted on 4/21/21.

The investigation consisted of the following: Previous administrator was interviewed during the initial visit and Resident #1's (R1) records were obtained. Seven additional staff were interviewed during the subsequent visit. Resident medications were reviewed and the facility was toured.

The investigation revealed the following: It’s alleged that residents in the dementia unit (South Garden) are not receiving their medications as prescribed. LPA reviewed the residents’ medication and discovered Resident #2 (R2) was missing Risperidone 1 mg daily tablet in the morning and Levocetirizine 5 mg daily tablet. Staff indicated they ordered the medication this morning and will hopefully get it today. Staff confirmed the resident did not get the medication today. 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: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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-20210414142230
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: 06/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was also confirmed staff in the dementia unit were using a rock or other type of object to crush the medication instead of using an actual medication crusher. Staff were also crushing the medication and putting the medication in a soda and giving the soda to Resident #3 (R3). Facility does not have a order to put the medication in soda. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Deficiencies are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided to administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210414142230
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: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2021
Section Cited
CCR
87465(a)
1
2
3
4
5
6
7
Incidental Medical and Dental Care (a) 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 medication as needed.
1
2
3
4
5
6
7
Facility will document the plan to prevent future medication errors. Plan will include staff training. Proof of training will also be submitted.
8
9
10
11
12
13
14
Deficiency was evidenced by the following: R2 was missing Risperidone 1 mg daily tablet in the morning and Levocetirizine 5 mg daily tablet. Staff were also using a rock or other type of object to crush the medication instead of an actual medication crusher. Staff were putting crushed medication in soda and giving it to R3 without order to give med with soda.
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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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
04/14/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210414142230

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: 159DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Priscilla Gaytan, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's care needs were not met resulting in a foot infection.
Staff did not schedule resident's podiatrist appointment.
Staff falsifies documents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with new administrator, Priscilla Gaytan and explained the reason for the visit. The initial complaint visit was conducted on 4/21/21.

The investigation consisted of the following: Previous administrator was interviewed during the initial visit and Resident #1's (R1) records were obtained. Seven additional staff were interviewed during the subsequent visit. Resident medications were reviewed and the facility was toured.

The investigation revealed the following: Allegation: Resident's care needs were not met resulting in a foot infection. Interviews conducted with staff indicate there is no proof Resident #1 (R1) had a toe infection. Some staff described R1’s toe as red or swollen. Staff indicated R1’s toe was being treated by facility staff. R1’s records were reviewed. There were no records found that indicated R1 had an infection. LPA observed pictures of what allegedly were R1’s feet, but it could not be confirmed there were R1’s feet and the pictures did not show an infection. Continued on 9099C.
Unsubstantiated
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: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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-20210414142230
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: 06/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1’s records indicate R1 is diagnosed with dementia and according to staff would not be able to communicate during an interview. R1 is currently in a skilled nursing facility due to declining health. Based on the information obtained the allegation is unsubstantiated.

Allegation: Staff did not schedule resident's podiatrist appointment. It’s alleged R1’s toenails were long because R1 was not seeing a podiatrist. Staff interviewed reported that the podiatrist was not entering the facility due to COVID-19. The podiatrist started visiting the facility earlier this year. R1 had an appointment but was told they would not take R1’s insurance. R1 was scheduled for another podiatrist appointment, but R1’s health declined and had to be transferred to the hospital in April 2021 and R1 has not returned to the facility. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff falsifies documents. It’s alleged staff document that residents in the dementia unit are assisted with their medication, but staff don’t actually give the medication. Staff interviewed deny the allegation. LPA reviewed the dementia unit medications and did not find evidence to support the allegation. LPA toured the dementia unit and did not find any residents that would be able to communicate effectively during an interview. Based on the 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 with administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5