191500609-8-5-2022-28-AS-MVAO-CH7UJ3-20220811153653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:36:52 PM

Unsubstantiated

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
03/24/2022 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220324131022

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: 150	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility staff member lacks qualifications.
Facility staff are not serving a good quality of food.
Facility staff confine residents in their rooms.
Facility staff does not ensure that residents are adequately hydrated.
Facility is not adequately staffed to meet the needs of the residents.
Facility is not kept clean.
Facility staff do not assist resident with oral hygiene needs.

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 3/29/22.

The investigation consisted of the following: Interviews were conducted with 6 staff and 11 residents. The facility was toured and resident records were reviewed.

The investigation revealed the following: Allegation - Facility staff member lacks qualifications. It's alleged facility staff are not competent enough to work with the elderly population they serve. Interviews conducted with residents did not support the allegation. Staff files were reviewed that caregivers and med techs have the required training and administrator has an administrator certificate. 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: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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-20220324131022

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: 08/05/2022

NARRATIVE

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Allegation - Facility staff are not serving a good quality of food. Interviews conducted with residents did not support the allegation. LPA observed breakfast being served in the dining room and residents were complimenting the food. Staff interviewed indicated the food is good and reported that staff also eat the food sometimes. The menu was reviewed and it had a variety of meats and meals being served. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility staff confine residents in their rooms. Interviews conducted with residents did not corroborate the allegation. Staff reported there was a stomach virus going around the facility sometime in March this year. The dining room was closed and all residents were getting trays. Staff deny residents were being confined to their rooms. Many residents were observed being out during today's visit and activities were being conducted. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility staff does not ensure that residents are adequately hydrated. Allegedly residents weren't receiving adequate hydration while the stomach virus was going around. Residents interviewed did not corroborate the allegation. Residents report getting juice, water, and coffee. Staff interviewed deny the allegation. LPA observed plenty of liquids being served during breakfast. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility is not adequately staffed to meet the needs of the residents. During the visit today there were 10 caregivers, 4 med techs, 1 LVN (Licensing Vocational Nurse), 9 housekeeping, and 2 maintenance staff. The majority of residents interviewed did not corroborate the allegation. Staff interviewed reported there is sufficient staff, but there are times that staff call-off. The facility uses a caregiver registry when staff call-off to cover each shift. There was insufficient evidence to prove this allegation.

Allegation - Facility is not kept clean. The facility was toured including the first and second floor, resident bedrooms, dining room, activity room, and kitchen. Maintenance was observed deep cleaning the carpets. The facility appeared clean at the time of the visit. Interviews conducted with staff and residents did not corroborate the allegation. Based on the information obtained, the allegation is unsubstantiated.

Continued on 9099C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220324131022

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: 08/05/2022

NARRATIVE

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Allegation - Facility staff do not assist resident with oral hygiene needs. Allegedly Resident #1 (R1) needs assistance with brushing his/her teeth and staff are not assisting. R1 was interviewed and denied needing assistance with oral hygiene. R1's file was reviewed. It indicated R1 is able to dress/groom self, handles own toileting needs and cash resources. R1 did not appear to need assistance with hygiene. Other residents interviewed reported not needing assistance with oral hygiene. Staff interviewed indicated they did have a staff member assist R1 with brushing his/her teeth once, but R1 did not want the assistance. 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: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

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