191500609-3-3-2022-28-AS-MVAO-CDGPXK-20220414114228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:51:06 PM

Substantiated

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
02/25/2022 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220225162408

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:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Karen Meacham (Community Liaison)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident's toileting needs are not being met in a timely manner.
Resident is not being treated with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Karen Meacham and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff Schedule and Resident Roster. LPA interviewed Residents #2 to #11 in the library between 10:45 am to 1:00 pm, interviewed Staff #1 in the library at 1:12 pm and interviewed Staff #2 in the library at 2:03 pm.

In regards to the allegation: Resident's toileting needs are not being met in a timely manner. Out of 10 Residents interviewed, 6 Residents either witnessed or was in need of toileting assistance corroborated that there were incidents of long wait times. Wait time for Staff to arrive and assist with toileting needs can be from 45 minutes to an hour.

Continue to LIC9099C.....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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-20220225162408

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: 03/03/2022

NARRATIVE

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In regards to the allegation: Resident is not being treated with respect. Out of 10 Residents interviewed, 5 Residents has witnessed incidents of Staff not treating Resident with respect. Incidents include Staff not knocking on the door before entering Resident's bedroom, provoking Resident and speaking to Resident in an inappropriate manner.

Based on LPA's interviews, investigation revealed 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 conducted with Karen Meacham and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220225162408

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: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2022 Section Cited CCR 87411(c)(3)B)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (c)(3)(B) importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control, as specified in Section 87470, Infection Control Requirements.	1 2 3 4 5 6 7	Licensee shall provide additional training to Staff ensuring Resident's toileting needs are met in a timely manner and Licensee shall provide proof of training to the department by the POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: 6 Residents either witnessed or was in need of toileting assistance corroborated that there were incidents of long wait times. Wait time for Staff to arrive and assist with toileting needs can be from 45 minutes to an hour.	8 9 10 11 12 13 14
Type B 03/17/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: 5 Residents has witnessed incidents of Staff	1 2 3 4 5 6 7	Licensee shall provide additional training to Staff ensuring Resident's personal rights to be accorded dignity is met and Licensee shall provide proof of training to the department by the POC date.
	8 9 10 11 12 13 14	not treating Resident with respect. Incidents include Staff not knocking on the door before entering Resident's bedroom, provoking Resident and speaking to Resident in an inappropriate manner.	8 9 10 11 12 13 14

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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