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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:48:28 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
02/16/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220216090335
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: 133DATE:
02/23/2022
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Administrator, Priscilla GaytanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility elevator is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Administrator, Priscilla Gaytan and explained the reason for the visit.

The investigation consisted of the following: Interviews were conducted with 10 residents and 6 staff. The facility was toured and elevator was tested.

The investigation revealed the following: The facility has 2 elevators, one near the front door and another near the dining area. Interviews conducted with staff revealed that the elevator near the dining room has stopped working. Maintenance staff was told by the elevator company to reset the elevator by turning the breaker on and off and the elevator will operate again. Staff deny anyone being trapped in the elevator. Residents interviewed confirmed that staff have reset the elevator and the elevator will start working again. Residents did not know of anyone being stuck in the elevator. Interviews conducted revealed that maintenance staff are quick to reset the elevator again. 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: 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)
Page: 1 of 2
Control Number 28-AS-20220216090335
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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LPA reviewed documentation from International Elevator Inc. which indicated they visited the facility on 2/22/22 and the elevator was operating properly. LPA tested the elevator twice during the visit at different times. Residents were also observed using the elevator. The elevator was operating properly at the time of the visit. 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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (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)
Page: 2 of 2