191500609-9-17-2021-28-AS-WSHO-C7LL8G-20211008083155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:40:56 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
09/13/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210913130021

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	PRISCILLA GAYTAN		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 153	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility is maintained in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo and Mora conducted a complaint visit to investigate the allegation listed above. LPA's met with administrator, Priscilla Gaytan and explained the reason for the visit.

The investigation consisted of the following: Interviews were conducted with fourteen residents and four staff. The facility was toured including resident bedrooms, hallways first and second floor, kitchen, dining room and common areas. LPA's also obtained a resident and staff roster.

The investigation revealed the following: It's alleged Resident #1's (R1) air conditioning unit is not installed properly in the room. LPA's entered the room and inspected the unit. The unit appeared to be installed properly and was operating. R1 indicated he/she moved into the room recently and the room was previously vacant. R1 indicated maintenance fixed the unit a short time later by adding weather stripping around the unit. Staff interviewed denied the allegation. Staff indicated the unit was never in disrepair and was always installed properly. 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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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-20210913130021

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: 09/17/2021

NARRATIVE

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There were no other witnesses that indicated the air conditioner unit was not installed properly. Based on the information obtained, the allegation is unsubstantiated.

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

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

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