191500609-1-3-2023-28-AS-MVAO-CPGUEJ-20230228143112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 01/03/2023
Date Signed: 01/03/2023 03:00:41 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
12/27/2022 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221227091743

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: 154	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Priscilla Gaytan- Assistant Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not prevent a resident from wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigasting the above-mentioned allegation. LPA Maldonado met with Assistant Administrator Priscilla Gaytan and explained the purpose for the visit.

During today's visit, LPA obtained a copy of the resident and staff roster, obtained the following documents for Residents# 1-4 (R1-R4): Facesheet, Physician's Report, Needs and Services Plan, and copies of incident reports for R2, and conducted interviews with Staff# 1-5 (S1-S5)

The investigation revealed the following:

(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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-20221227091743

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: 01/03/2023

NARRATIVE

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Regarding allegation: Staff did not prevent a resident from wandering away from the facility.
It is alleged that the facility is experiencing issues with 4 residents who reside in the Memory Care Unit, that have figured out ways of getting out, and R1 has managed to escape property grounds on 3 different occasions. After review of the resident roster, it has been noted that R1 is not a resident at this facility. The Memory Care Unit is a gated wing of the facility. Each gate door to enter/exit has a protector around the doorknob to make it difficult for residents to try to leave. If the protector is held and turned correctly, the door knob could be opened; However there is an alarm that will sound if a code is not entered in the gate system. During interviews conducted, (5) of (5) staff confirmed that R2 was the resident whom they were experiencing issues with. All staff interviewed stated that R2 was adamant about leaving the facility at any opportunity found, and found different ways of doing it. All staff state to have noticed R2 always standing by the gate and watching them enter the gate code to try to learn it. When R2 would figure out the code, R2 would use it to try to leave the facility without being noticed. Due to all staff being aware of the resident's behaviors, R2 was checked on frequently and as soon as R2 was noted not to be nearby, staff would head out to nearby stores, where R2 was noted to frequent, find R2, and bring R2 back to the facility quickly and safely. All staff interviewed stated that local law enforcement was called on one occasion when R2 was not located immediately, as it was getting dark outside. R2 was noted to have returned on one's own shortly after law enforcement had arrived to assist with locating R2. All staff interviewed state to have been on high alert regarding R2 and many different things were done to try to prevent the resident from leaving the facility unassisted, such as changing the gate code multiple times and assigning a caregiver to provide one-to-one supervision. S2 also stated to have walked with R2 to a store nearby when R2 was noted to have left the facility and refused to go back. Per S1 and S2, R2's responsible party voluntarily moved R2 to a different facility to assist with meeting R2's needs, as the responsible party was well aware of the situation.

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 allegation is UNSUBSTANTIATED.

An exit interview was conducted with Assistant Administrator Priscilla Gaytan and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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