191500609-10-28-2022-28-AS-RORN-CKRP78-20221101110332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:33:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 149	DATE:	10/28/2022
		UNANNOUNCED	TIME BEGAN:	04:01 PM
MET WITH:	Priscilla Gaytan, Assistant Administrator		TIME COMPLETED:	04:30 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 follow up visit to add LPA's name that was omitted on the report issued on 10/25/22. This report supersedes the reports provided on 10/25/22 and 9/14/22 with the substantiated outcome. After additional review of the documents and interviews, the allegation stated above is now unsubstantiated.

On 10/25/22, LPA Chan conducted a subsequent visit to deliver finding for the allegation listed above. LPA met with Administrator, Karen Meacham, and Assistant Administrator, Priscilla Gaytan. The purpose of the visit was explained.

On 9/14/22, LPA Chan obtained 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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 2

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
	VISIT DATE: 10/28/2022

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 with one hand, hoping to stop the elevator door from closing, but ended up crushing the hand. It also indicated the older elevators do not have infrared device to detect a motion.
LPA interviewed Administrator Edwards who stated that the elevators have sensors to detect any object approaching the door. The administrator was not aware of anybody getting injured from the elevator door. The staff interviewed had not heard of the incident where a person's hand got injured from the elevator door closing on it. The staff had not tried to approach the door by sticking in their hands as it is closing. Instead, they would press the outside button to get the elevator door to retract. They stated that the elevators have sensors on them which will prevent the door from closing on the residents as they are entering. LPA interviewed 11 residents and 10 out of 11 residents stated they do not have any issues with the elevators. 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, LPA tested the 2 elevators in the building with the Assistant Administrator. Both elevators detected LPA’s hand or foot when the doors were closing mid-way. The elevator doors also retracted when LPA pressed the button from the outside. Based on observation, the elevators appear to work properly and have door sensors. Reports gathered show that an elevator inspector comes out on a monthly basis. LPA reviewed the elevator service reports and there were no indications of the elevator in disrepair. A representative from the elevator company confirmed the services at the facility and that the elevators have motion sensors installed.

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.

An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Assistant Administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2