191500609-6-23-2022-28-AS-MVAO-CH7TUK-20220811150230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:57:44 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
01/26/2022 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220126120119

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: 145	DATE:	06/23/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility serves resident food that is not eatable.
Facility opens resident's mail.
Facility is giving resident medication that is not prescribed.
Facility is charging resident for services not received.
Facility does not serve meals at scheduled times.

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 2/2/22.

The investigation consisted of the following: Interviews were conducted with 8 residents and 4 staff. Resident #1's (R1) file was reviewed which included physician's report, psychiatric notes, conservatorship documents and medication records.

The investigation revealed the following: Allegation - Facility serves resident food this is not eatable. Interviews conducted with residents revealed that the food has been better and there is more variety. Staff interviewed included management, Licensed Vocation Nurse (LVN), and caregiver. Staff indicate the food is good and reported that staff eat the food as well. The food was observed during the visit and there were no issues observed. 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: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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-AS-20220126120119

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: 06/23/2022

NARRATIVE

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Allegation - Facility opens resident's mail. Residents interviewed stated they have never had issues with staff opening their mail. Each resident has a mail box near the front office. Staff interviewed deny knowing of anyone opening residents' mail. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility is giving resident medication that is not prescribed. It's alleged facility is providing R1 with medication that is no longer prescribed. R1's records contained psychiatric notes that discontinued R1's Zyprexa medication on 10/18/21. Allegedly staff continued to give the medication after the discontinuation order. Staff interviewed denied the allegation. R1's medication records were reviewed and the Zyprexa medication is no longer listed on the Medication Administration Record (MAR). Psychiatric notes indicate R1 was on and off the Zyprexa medication in 2020. Other residents interviewed did not report any medication issues. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility is charging resident for services not received. It's alleged facility is charging R1 for blood pressure monitoring and laundry service and facility is not providing those services. Staff interviewed indicated R1 sometimes does not allow staff in his/her room. Staff does assist with blood pressure monitoring when R1 allows staff inside. All staff indicated R1 is verbally aggressive sometimes and will shut the door in their face. Staff also report and document when R1 refuses medications and meals because he/she does not want anyone in the room. Staff reported that the laundry also gets done with R1 allows staff inside. Other residents interviewed reported no issues with overcharges and reported facility provides the services indicated on the admission agreement. LPA attempted to contact R1's conservator several times, however conservator has not called back. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Facility does not serve meals at scheduled times. Residents interviewed did not corroborate the allegation. Residents interviewed included some that go to the dining room and some that receive trays in their rooms. None of them reported having issues with the meal times. Staff interviewed indicated everyday the meals are served at the same time. 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: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC9099 (FAS) - (06/04)

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