191500609-3-22-2022-28-AS-WSHO-CCYRFQ-20220329125931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:26:08 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
03/16/2022 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220316142527

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: 134	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Priscilla Gaytan, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff retaliates against resident.
Staff makes false statement regarding resident.
Staff did not assist resident with obtaining medical care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations 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 4 staff and 3 residents. Resident #1's (R1's) records were reviewed. The facility was toured.

The investigation revealed the following: Allegation - Staff retaliates against resident. It's alleged facility is retaliating against R1 for his/her behavior and as a result is attempting to evict R1. Staff interviewed deny R1 is being evicted and denied threatening R1 with eviction. R1 indicated he/she has not received an eviction notice. R1 indicated no one else heard or witnessed the threats made by staff. There were no other witnesses to the alleged incident and no eviction notice was served. Based on the information obtained, the allegation is unsubstantiated.
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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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-AS-20220316142527

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: 03/22/2022

NARRATIVE

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Allegation - Staff makes false statement regarding resident. It's alleged staff say R1 smokes in his/her room. Staff interviewed indicated they have witnessed R1 light cigarettes in the room and then goes out to the smoking area which is near R1's room. Staff indicated that R1 has been warned about lighting the cigarettes in the room. R1 reported that he/she admitted to staff that they have smoked in the room in the past, but not recently and has stopped doing it. Based on the information obtained, this is not a false statement made by staff and is unsubstantiated.

Allegation - Staff did not assist resident with obtaining medical care. It's alleged R1 had a scheduled medical appointment on 3/16/22 and facility never assisted with transportation. The facility appointment book was reviewed. R1 did have a scheduled appointment on 3/16/22. R1 was interviewed and R1 confirmed that he/she went to the scheduled appointment. R1 inquired about a follow-up appointment for imaging that he/she thought staff forgot about. R1 was told they have another scheduled appointment on 3/30/22 for imaging and staff is aware and will transport to appointment. Based on the information obtained, R1 has not missed any medical appoints. Therefore, 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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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