191500609-2-2-2023-28-AS-RORN-CNUQXX-20230208113415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:36:58 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
05/20/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220520141648

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:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Priscilla Gaytan – Assistant Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not provide adequate food service
Staff did not treat resident with respect
Staff did not meet resident's medical needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Priscilla Gaytan (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 05/26/2022, LPA obtained copies of resident and staff rosters, April and May 2022 menu, and facility nurses' notes for Resident 1 (R1). Interviewed the Assistant Administrator, Staff #1 (S1), and Resident #1 (R1). Today's visit, LPA obtained copies of resident and staff rosters, January and February 2023 menu and alternative menu. LPA also interviewed Staff 2 - Staff 4 (S2 - S4) and Resident 1 - Resident 15 (R1 - R15).

The investigation revealed the following: regarding the allegation "staff did not provide adequate food service", it is alleged that the food the facility serves is not good and is not nutritious.
(Continued to LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20220520141648

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: 02/02/2023

NARRATIVE

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The Assistant Administrator stated that she does not agree with the allegation and that they have made many improvements on their food. She also stated that the facility has registered dietitian that gives them guidance and a recipe book to follow. Residents interviewed revealed that 9 out of the 15 residents could not corroborate with the allegation.

Regarding the allegation "staff did not treat resident with respect", it is alleged that when a resident complains about the food, the staff respond with if you don’t like the food then you can leave it. Administrator and staff interviewed denied the allegation. Residents interviewed revealed that 14 out of the 15 residents could not corroborate with the allegation.

Regarding the allegation "staff did not meet resident's medical needs", it is alleged that a resident has severe shoulder pain and facility has only taken the resident to the doctor 3 times within a 12 month period. It is also alleged that the facility changed the resident's doctor without the resident's consent. Review of facility's nurse notes show that the facility's LVN has been trying to get a pain management doctor to see the resident as of 11/11/2021. An appointment was made for 12/15/2021 11:00am and when the LVN called the pain management doctor's office on 12/14/2021 to confirm the appointment the LVN was told that unfortunately a referral from the resident's primary doctor is needed before the pain management doctor can see the resident. On 12/15/2021, the facility's LVN contacted the resident's primary doctor and was told that this doctor is no longer the primary doctor for the resident due to the doctor is no longer part of the resident's health insurance network. They provided the LVN with contact information of the new primary doctor that was assigned to the resident. A tele visit appointment was made with the new primary doctor for 12/28/2021 and the referral to see a pain management doctor was requested. LVN called this new primary doctor office on 01/21/2022, 01/25/2022, and 02/02/2022 requesting an update on the referral. On 04/13/2022, the resident was taken to see the pain management doctor, but the resident got upset and walked out of the clinic. On 04/14/2022, the facility LVN try to convince resident to return to the see the pain management doctor, but the resident refused because the doctor is not helping at all. Residents interviewed revealed that 14 out of 15 residents could not corroborate with the allegation.

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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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