191500609-6-10-2021-28-AS-WSHO-C7AMAK-20210928092625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/09/2021
Date Signed: 06/10/2021 09:17:34 AM

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
03/29/2021 and conducted by Evaluator Glenn Trueman

COMPLAINT CONTROL NUMBER: 28-AS-20210329100217

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: 159	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not issue a refund
Staff took residents personal items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman 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 4/06/21.
The investigation consisted of the following: Previous administrator was interviewed during the initial visit and Resident #1's (R1) records were obtained. Today 06/09/2021.Resident's 2-6 were interviewed from 1:45 PM to 2:45 PM.
Power of Attorney (POA) for Resident # 1 was interviewed at 10:00 AM 06/09/2021.
Staff Supervisor Roxanne Flores was interviewed at 2:45 PM.
In regards to the allegation staff didn't issue a refund, based on interviews conducted with Administrator and Power of Attorney (POA) for Resident # 1 POA stated that by law he did research and it was revealed that SSI check can not be cashed within 30 days of a a resident being deceased. POA thus wrote void on the check and returned it. It was dated 3/16/2021 in the amount of $2295.06.
Details of the events of POA were confirmed in the interview with the previous Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20210329100217

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: 06/09/2021

NARRATIVE

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Facility did mail a check to family member of Resident # 1 on 04/05/2021.
Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

In regards to the allegation Staff took residents personal items, based on interviews all 5 resident's interviewed stated that they have all their personal property and nothing has been missing
Stated that they will walk all over the facility and leave the door open and nothing has ever been stolen.
Stated that staff are professional and have not taken any items from their rooms.
In regards to Resident # 1's property it was revealed that property had been returned to family member of resident # 1 and remaining items had been made available for pick up.
POA stated that there was a little furniture and small television and family member would not pick it up and it was left there with facility unable to rent room. but facility was making property available for pick up.
It should be noted that 3/21/21 family member did pick up some belongings.
3/26/2021 family member was contacted to pick up the rest of the belongings.
LPA toured Resident # 1's room # 28 A and interviewed Supervisor for that room who stated that family member came in March and they helped her with belongings.
They also had many facetime calls with family member.
She had come in March and stated she would be back the following weekend, but hasn't.
Room still has wheelchair, lamp, clothing and small television occupying the room.

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 allegation is unsubstantiated.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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