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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 09/30/2021
Date Signed: 09/30/2021 04:00:21 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
09/08/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210908115240
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 153DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Priscilla Gaytan, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is short staffed.
Facility is mismanaging the resident(s) medication(s).
Staff are not administering medications to residents as prescribed.
Resident's dietary needs are not being met.
Food services are inadequate.
Facility is dirty.
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 9/17/21. A subsequent complaint visit was conducted on 9/22/21.

The investigation consisted of the following: During the initial and subsequent complaint visits, a total of twenty-two residents and fourteen staff were interviewed. The facility was toured including resident bedrooms, hallways on the first and second floor, kitchen, dining room and common areas. During today's visit two additional staff and two residents were interviewed and the medication room was inspected today.

The investigation revealed the following: Allegation: Facility is short staffed. Staff interviewed included Medical Technician's (Med Techs), Licensed Vocational Nurses (LVN's), caregivers, food service staff, housekeeping and administration.
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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 7
Control Number 28-AS-20210908115240
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: 09/30/2021
NARRATIVE
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Nine out of the sixteen staff interviewed agreed the facility is short staff. It was reported that dietary is short staff when staff call off. Med Techs are short staff in the 3 pm - 11 pm shift and on the graveyard. Staff report that residents have received medications late and or treatments. Many Med Techs are asked to cover shifts when people call off. On the 3 pm - 11 pm shift many times there are two Med Techs passing medication for the first floor, second floor, garden area, and memory care unit. According to staff, that is not enough people to pass medication. Sixteen out of the twenty four residents interviewed agreed facility is short staff, particularly in the Med Tech department. Residents reported receiving their medications or treatments late or not at all. Residents reported seeing many of the staff working double shifts because according to residents, the facility is short staff. Based on the information obtained, the allegation is substantiated.

Allegation: Facility is mismanaging the resident(s) medication(s). As mentioned above, staff confirmed residents are receiving medications and treatments late. Treatments include ointments, eye drops, and breathing treatments. Residents confirmed they have received medications and treatments late. One resident mentioned they had a hard time breathing and had to wait for hours until the Med Techs assisted with the prescribed inhaler. Based on the information obtained, the allegation is substantiated.

Allegation: Staff are not administering medications to residents as prescribed. As mentioned earlier staff confirmed medications and treatments are being administered late. Residents confirmed they are receiving medications and treatments late or they don't get them at all. Based on the information obtained, the allegation is substantiated.

Allegation: Resident's dietary needs are not being met. Sixteen out of the twenty four residents interviewed agreed their dietary needs are not being met because the food is bad. Residents reported the meats are dry and sometimes undercooked. They report too much pork is being served and there are not enough options if residents don't want what is on the menu. Yogurt used to be an option for residents in the morning, but that is no longer available. According to kitchen staff, yogurt is no longer in the budget. It was reported that the drinks are watered down and taste bad. Several residents reported they have lost a lot of weight because they don't eat the food in the facility. All the staff interviewed confirmed residents do complain about the food often. The facility did contract with a different meat vendor, however residents still complain about how the meats are cooked. Based on the information obtained, the allegation is substantiated.

Continued on 9099C.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20210908115240
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: 09/30/2021
NARRATIVE
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Allegation: Food services are inadequate. As mentioned above, residents confirmed they are not happy with the food and many choose not to eat it. Also many residents indicated the food is cold when it's served. Due to COVID-19 many residents are choosing to eat and be served in their rooms instead of entering the dining room. Once the meals are served in the rooms the food is cold. Some staff interviewed confirmed the food is cold by the time the food is served to residents in their rooms. Based on the information obtained, the allegation is substantiated.

Allegation: Facility is dirty. It's alleged the carpet in the hallway is stained. LPA toured the facility and noticed there were several stains on the second floor carpet in the hallway. According to staff, maintenance is responsible for deep cleaning the carpets. However, there has been a shortage of maintenance staff and therefore, the carpets have been neglected. At one point the facility only had two maintenance staff for a building of a capacity of 343. The facility has since hired one additional maintenance staff. Based on the information obtained, the allegation is substantiated.

Based on LPAs observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are 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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20210908115240
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: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2021
Section Cited
CCR
87411(a)
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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....
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Administrator is in the process of interviewing staff. The registry cannot be used as Med Techs because they are not trained on medications. Facility must hire additional staff to meet the needs of the residents. Staffing plan will be submitted by 10/1/21.
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Deficiency was evidenced by the following:
Nine out of the sixteen staff interviewed agreed the facility is short staff. Fourteen out of the twenty two residents interviewed agreed facility is short staff. Residents are receiving medications and treatments late. Staff are not respond in a timely manner when residents call for assistance.
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Type A
10/01/2021
Section Cited
CCR
87465(a)(5)
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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:(5) The licensee shall assist residents with self-administered medications as needed.
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Staffing will be updated to meet the needs of the residents. Administrator will submit staffing plan to describe how facility will mee the needs of the residents. Plan sill be submitted by 10/1/21.
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Deficiency was evidenced by the following:
staff confirmed residents are receiving medications and treatments late. Treatments include ointments, eye drops, and breathing treatments. Residents confirmed they have received medications and treatments late.
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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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20210908115240
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: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited
CCR
87555(a)
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General Food Service Requirements
The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and .......
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Administrator will ensure kitchen staff have been trained in meal preparation to meet the needs of the residents. Plan detailing training will be submitted by 10/14/21.
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Deficiency was evidenced by the following:
Fourteen out of the twenty two residents interviewed agreed their dietary needs are not being met because the food is bad. Residents reported the meats are dry and sometimes undercooked. They report too much pork is being served and there are not enough options. Food is also served cold.
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Type B
10/14/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Facility has since hired an additional maintenance staff. Facility will provide proof that carpets have been deep cleaned on the second floor.
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Deficiency was evidenced by the following:
LPA toured the facility and noticed there were several stains on the second floor carpet in the hallway. According to staff, maintenance is responsible for deep cleaning the carpets. However, there has been a shortage of maintenance staff and therefore, the carpets have been neglected.
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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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/08/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210908115240

FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 153DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Priscilla Gaytan, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident's are not being provided activities.
Untrained staff administering medication.
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 9/17/21. A subsequent complaint visit was conducted on 9/22/21.

The investigation consisted of the following: During the initial and subsequent complaint visits, a total of twenty-two residents and fourteen staff were interviewed. The facility was toured including resident bedrooms, hallways on the first and second floor, kitchen, dining room and common areas. During today's visit two additional staff and two residents were interviewed and the medication room was inspected today.

The investigation revealed the following: Allegation: Resident's are not being provided activities. Residents interviewed denied the allegation. Residents indicated volunteers from a local college visit and conduct activities with residents. Residents report doing activities such as bingo and word games. The activity director recently resigned, however the facility has hired a new activity director. During today's visit, LPA observed residents engaged in activities. Based on the information obtained, the allegation is unsubstantiated. 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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20210908115240
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: 09/30/2021
NARRATIVE
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Allegation: Untrained staff administering medication. Allegedly there is an employee of the facility that is a driver and is also assisting residents with medication. Staff training was reviewed and it was confirmed the driver has the training on file. The driver was interviewed and also confirmed the medication training. Med Techs interviewed stated all staff assisting with medications have been trained properly. None of the residents interviewed indicated having any medication issues that included the driver in question. 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. 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: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7