191500609-6-16-2021-28-AS-WSHO-C6X257-20210916170504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/16/2021
Date Signed: 06/16/2021 01:03:43 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
06/07/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210607111336

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: 158	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Priscilla Gaytan, administrator		TIME COMPLETED:	01:12 PM

ALLEGATION(S):

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Staff did not prevent inappropriate behaviors between residents.
Staff are not providing adequate food service to residents.
Staff are not providing adequate linens for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with administrator, Priscilla Gaytan and explained the reason for the visit. The initial complaint visit was conducted on 6/11/21.

The investigation consisted of the following: 7 staff and 11 residents were interviewed. Facility was toured which included the kitchen, dining room, common areas, and resident bedrooms. Resident and staff roster were obtained along with the facility menu.

The investigation revealed the following: Allegation: Staff did not prevent inappropriate behaviors between residents. It’s alleged Resident #1 (R1) was kissed by another resident in the hallway near the other resident’s room. R1 reportedly told the previous administrator about the issue. R1 reported that the previous administrator was made aware of the situation and R1 was asked if he/she wanted to call the police. R1 reportedly did not want the police involved. Previous administrator spoke to the other resident and the issue never happened again. 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: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210607111336

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: 06/16/2021

NARRATIVE

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Staff and residents interviewed reported that they have not seen any inappropriate interactions between residents. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff are not providing adequate food service to residents. It’s alleged the food quality is poor and the food is sometimes served cold. 7 out of the 11 residents interviewed indicated the food is good and is served warm. The other 4 residents indicated the food could be better. Those residents indicated the meat is tough to eat sometimes and there isn’t a variety of food. The other 7 residents indicated the meat is good, it’s served warm, and there is a lot of variety of food. Residents also reported having options if they didn’t want what was on the menu. LPA observed breakfast and lunch being served. The food was warm and the kitchen served what was listed on the menu. The kitchen was toured. The walk-in refrigerator had a variety of meats including chicken, pork, and red meat. There were also fresh vegetables and fruit. The menu appeared to have a variety of different food. There is insufficient evidence to prove the allegation, therefore allegation is unsubstantiated.

Allegation: Staff are not providing adequate linens for residents. It’s alleged the linen is torn. Staff interviewed reported they have not received any complaints about the linen and have not seen torn linen. Residents interviewed reported that staff change the linen often and the linen is never torn. LPA toured resident bedrooms and did not observe any torn linen. 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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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