191500609-9-14-2022-28-AS-RORN-CKRP7A-20221101110333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:14:20 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
09/06/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220906133127

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: 152	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cynthia Edwards, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

The facility elevator is not in good operating condition.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with Administrator, Cynthia Edwards. The purpose of the visit was explained. Assistant Administrator, Priscilla Gayton, assisted LPA with the visit today.

The investigation consisted of the following:

LPA obtain copies of the staff roster, resident roster, and service reports for the elevator for this year. LPA toured the facility and tested the 2 elevators. Interviews were conducted with the Administrator, Assistant Administrator, 7 Staff, 11 Residents, and a representative of the International Elevator Inc.

(Continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20220906133127

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: 09/14/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:

For allegation – The facility elevator is not in good operating condition. It is alleged that a person reached in hoping to stop the elevator door from closing, but it was crushing the hand. The elevator did not sensor the object and the individual had to pull the out hand instead. LPA interviewed the Administrator who stated that the elevator has a sensor to detect any object approaching the door. However, if someone was to put the hand last minute, it will not detect it and the elevator will continue to close. None of the additional staff interviewed had heard of this issue and had not tried to approach the door, at the last seconds, as it is closing. They stated that the elevators have sensors on them which will prevent the door from closing on the residents as they are entering or trying to enter. LPA interviewed 11 residents today and 10 out of 11 residents stated they do not have any issues with the elevators closing on them. Some stated that when the elevator door starts to close, they do not attempt to open the door and will wait for the next round. One resident reported that the elevator did not detect the cane as resident tried to use it to keep the door from closing. During the visit today, LPA tested the 2 elevators in the building with the Assistant Administrator. Based on observation, both elevators can only detect LPA’s hand or foot when the doors were closing mid-way. However, as LPA tried to reach in the last 2 seconds as the doors were shutting, the sensor did not pick up LPA’s hand or foot. Therefore, LPA needed to retract them as the door was continuing to close. LPA interviewed a representative from the International Elevator company that services the facility and it was reported that the elevator should not close when something is detected even at the last seconds.

Based on LPA observation and interview, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with Administrator Edwards. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220906133127

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: 09/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 09/30/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as	1 2 3 4 5 6 7	The Administrator shall ensure the elevators are working properly and detect any objects as it is closing. The Administrator will send over the elevator service invoice by POC due date 9/30/22.
	8 9 10 11 12 13 14	Based on observation, the elevators did not detect any moving objects when the door was closing more than half way which poses a potential health and safety issue to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3