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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500609
Report Date: 04/01/2021
Date Signed: 04/01/2021 03:31:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:FERNANDA KEYFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 161DATE:
04/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator / Fernanda KeyTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted telephonically with Fernanda Key, the Administrator.

During today's tele visit, LPA Katrdzhyan interviewed the Administrator and gathered additional details surrounding the death of Resident #1 (R1), which occurred on 04/01/2021. The LPA also requested copies of the following documents in reference R1. Documents were requested to be sent via email to the LPA’s attention by no later than the end of business day on 04/01/2021;

• Admission Agreement • Pre-placement Appraisal Information • Functional Capability Assessment
• Physician's Report • Appraisal/Needs and Services Plan • List of Medications • Incident Report • Death Report • Power of Attorney Documentation • LIC 621/Resident Personal Property And Valuables • Resident Roster • Staff Roster.

At this time, the investigation remains open as additional information is needed before a decision can be rendered.

A telephonic exit interview was conducted with Fernanda Key, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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