191500609-9-15-2022-28-AS-RORN-CJPVN6-20220928163434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:31:25 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
08/30/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220830095931

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: 151	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Priscilla Gaytan - Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility has insects

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Priscilla Gaytan (Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 09/07/22, LPA Flores conducted an initial complaint investigation and requested copies of staff/resident roster and 3 months of pest control services. LPA observed activity room, lobby, and conference room. Today's visit, LPA Mora conducted a tour of 15 residents' bedrooms and common areas, and interviewed Assistant Administrator, Staff 1 - Staff 3 (S1 - S3), and Resident 1 - Resident 15 (R1 - R15).

The investigation revealed the following: regarding the allegation "facility has insects", it is alleged that a resident is getting bug bites at night inside the resident's bedroom and facility has not communicated with this resident to resolve the issue. (CONITNUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220830095931

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: 09/15/2022

NARRATIVE

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Administrator and staff interviewed denied the allegation and stated that they have been in constant communication with the resident since the resident brought this issue to them. They claim that they did a full clean up and inspection of the bedroom twice (before and after the pest control service that was conducted on 08/19/22) and no insects were found. They changed the residents mattress, scheduled the earliest pest control service available (08/19/22) and even offered the resident to move to another room which the resident refused. Residents interviewed revealed that 13 out of 15 residents were unable to corroborate with the allegation. The other 2 residents stated that they have seen insects in their bedrooms and have been bitten. One of these residents showed the LPA pictures of insects. However, when reviewing the pictures some of them were not clear and LPA was unable to determine if it was a stain or an insect on the towels. The other pictures appeared to be taken outside the bedroom/facility and some pictures were of insects killed inside a napkin, but LPA was unable to determine if the insect were killed inside the bedroom/facility or outside. This resident did state that since pest control serviced the bedroom on 08/19/22 and staff cleaned the carpet of the bedroom that there has been no sign on insects or bugs anymore. The other resident claimed to be bitten last night inside the bedroom. No insect bites were observed on their bodies during the visit. LPA toured all the bedrooms of the 15 residents that were interviewed and common areas, and observed no insects or bugs. The Western Exterminator Company service inspection reports for the last 3 months including the one done on 08/19/22 state that no pest activity was found.

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.

Exit interview held and a copy of the report was provided

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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