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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:51:14 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
09/15/2022 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20220915160450
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 150DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Priscilla Gaytan- Assistant AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff do not treat residents in care with respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with assistant administrator Priscilla Gaytan and explained the purpose for the visit.

On 09/21/22, LPA Maldonado obtained a copy of the resident and staff roster, interviewed Residents# 1-8 (R1-R8) and staff# 1-#8 (S1-S8).

During today's visit, LPA Maldonado interviewed R9-R11 and reviewed files for S1-S8 to look for the required annual training.



(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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 5
Control Number 28-AS-20220915160450
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: 10/06/2022
NARRATIVE
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Regarding Allegation: Staff do not treat residents in care with respect.
During interviews conducted with R1-R11, (4) of (11) residents stated they are not treated with respect, and have witnessed other residents not being treated with respect by staff. R2 stated to have been denied assistance by staff rudely when R2 asked to see a nurse. R4 stated staff never come to assist when R4 uses the call button to be helped with toileting during the night time. R4 has been told repeatedlyin a rude manner that they are busy and will come later. R5 states staff constantly speak rudely to R5 when it is time to take medication because R5 sometimes does not want to take it, and staff try to force R5 to take it. R8 stated that anytime staff is called to assist with toileting, they take an hour to arrive, and when staff answer the call, they answer in a rude tone and tell R8, "You need to wait. We are busy. You are not the only one asking for help." R8 also states that there is a staff in the morning who gives R8 their medication who is mean/rude. R8 has witnessed this staff to be rude/mean to other residents because they do not get to the door quick enough for their medication. R8 states some staff have no patience for residents.

Based on LPA's observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/15/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220915160450

FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 150DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Priscilla Gaytan- Assistant AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff speak inappropriately in front of residents in care.
INVESTIGATION FINDINGS:
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5
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7
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9
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13
Licensing Program Analyst (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with assistant administrator Priscilla Gaytan and explained the purpose for the visit.

On 09/21/22, LPA Maldonado obtained a copy of the resident and staff roster, interviewed Residents# 1-8 (R1-R8) and staff# 1-#8 (S1-S8).

During today's visit, LPA Maldonado interviewed R9-R11 and reviewed files for S1-S8 to look for the required annual training.



(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220915160450
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: 10/06/2022
NARRATIVE
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Regarding allegation: Facility is not ensuring that staff are properly trained.
During interviews conducted with S1-S8, it was stated that on-boarding training is provided upon hire which includes video training and shadowing someone with the same working title. Assistant administrator Priscilla stated that a new staff's prior experience does not determine the length of training, as all staff are provided the same amount of training. Priscilla states is aware of an incident where a staff, who is no longer working at the facility, mentioned they were not comfortable with going on their own upon completion of their training. Priscilla brought this to the attention of the the lead staff for this training, and coordinated additional training time for the staff who requested it. During interviews conducted with S1-S8, (5) of (8) staff stated new staff should be provided more hands-on training prior to working individually and without supervision. (3) of (8) staff stated they would prefer to be provided more on-going training regarding medication. Based on records review, it was discovered that (7) of (8) staff have not received the required full hours of training needed for the year. Based on interview conducted with Priscilla, all staff will complete the required training prior to the end of the year. It was also discovered that staff were provided the appropriate on-boarding training as required.

Regarding allegation: Staff speak inappropriately in front of residents in care.
During interviews conducted with R1-R11, (10) of (11) residents stated they have no knowledge of an incident where a staff spoke inappropriately in front of them or other residents in care. All residents interviewed stated if they had knowledge, they would have reported it to the administrator or another staff. During interviews conducted with S1-S8, (8) of (8) staff stated they have no knowledge of an incident where staff spoke inappropriately in front of residents in care. All staff interviewed stated if they had knowledge of an incident of that nature, they would have reported it to the administrator.

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 with assistant administrator Priscilla Gaytan and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220915160450
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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
Thie requirement was not met as evidenced by:
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Administrator to conduct Personal Rights training and provide a copy of the sign in sheet with material to the LPA by POC due date.
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Based on interviews conducted, (4) of (11) residents in care stated they were not being treated with respect by staff in the facility, which poses a potential Health, Saftey, or Personal Rights risk to persons in care.
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HSC
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5