191500609-2-23-2022-28-AS-MVAO-CCDUYV-20220310150035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:49:10 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
12/07/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-NP-20211207083241

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:	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 133	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff failed to provide adequate food service.
Staff failed to administer medication as instructed by physician.

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 12/14/21.

The investigation consisted of the following: Interviews were conducted with 10 residents and 5 staff. The facility was toured which included the kitchen at the time breakfast was being served. 6 residents' medications were also reviewed.

The investigation revealed the following: Regarding the food allegation, there were no details provided other than a black and white picture of food. Interviews conducted with residents revealed that the food has improved recently due to staff changes in the kitchen. Staff interviewed reported that they have also received positive feedback regarding the food recently. LPA toured the kitchen and observed breakfast being served. The kitchen was clean and had sufficient perishable and non-perishable food. 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: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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-NP-20211207083241

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: 02/23/2022

NARRATIVE

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Based on the information obtained, the allegation is unsubstantiated.

Regarding the medication allegation, it's alleged dinner medication and bedtime medication are being given at the same time. Residents interviewed did not corroborate the allegation. Staff indicated they have not witnessed this issue and had no knowledge of the alleged medication issue. Residents' medications were randomly chosen for review. There were no issues found with the medications. 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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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