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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:30:55 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
10/17/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221017082225
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: 149DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Keren Meacham- AdminstratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident was illegally evicted.
Staff failed to prevent resident from AWOL’ing from facility.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with administrator Karen Meacham and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and conducted a tour of the physical plant with the administrator. LPA Maldonado also requested a copy of the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, Incident Reports for July-October 2022, and a copy of the eviction notice, if available. Interviews were conducted with Staff# 1-7 (S1-S7).



(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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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-20221017082225
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: 10/24/2022
NARRATIVE
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Regarding allegation: Resident was illegally evicted.
It was alleged that R1, a memory care resident, had a series of incidents where R1 tried to leave the facility unassisted. Due to an increase of incidents, most of them being successful, the resident was sent to the hospital for a psych evaluation to determine if the resident needed a higher level of care. The facility has a secured memory care unit that is under surveillance and staffed with caregivers to oversee the residents. It is not a locked perimeter. During interviews conducted with S1-S7, (7) of (7) staff stated they were notified R1 was discharged from the facility, unknown why. Per interviews with S1-S7 and review of documents obtained, an eviction notice was not issued to R1, otherwise staff would have knowledge. S2 stated that S8 was the interim administrator at the time of the incidents leading to R1 leaving the facility, and was responsible for making the decision of R1 not returning. S3 stated they spoke to R1's responsible party and was told they were seeking new placement for R1 since R1 could not return to the facility, per S8. A reassessment of R1 by the facility was not conducted to receive R1 back, following discharge from the hospital. Therefore, the resident was evicted illegally. This allegation is substantiated.

Regarding allegation: Staff failed to prevent resident from AWOL’ing from facility.
During interviews conducted with S1-S7, (7) of (7) staff state that R1 fled from the facility on several occasions without assistance. Per R1's Physician's Report, R1 was unable to leave the facility unassisted due to diagnosis of dementia. R1 resided in the facility's memory care unit, which is a secured perimeter, not locked. The perimeter has surveillance cameras and alarm systems when the doors are opened. All staff interviewed have knowledge of the resident being able to open the doors of the secured area and leaving, but did not request a psych evaluation for R1 until 9/13/22 for reassessment of the level of care R1 needed. During an incident occurred on 9/12/22, R1 AWOL'ed (absence without leave) from the facility. Local law enforcement had to be notified and a facility staff found R1 at the shopping center across the street from the facility about 1 hour after the resident went missing. This allegation is substantiated.

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.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with Administrator Karen Meacham and a copy of the 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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20221017082225
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: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures
(a) The licensee may evict a resident...Thirty (30) days written notice to the resident is required...(4)If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted... and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.
This requirement was not met as evidenced by:
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The facility will reassess the resident as appropriate and determine if the resident is able to return to the facility. If unable to, a proper 30 day written notice will be issued. In either case, the licensee will provide a copy of the determination and supporting documents via email by the POC due date.
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Based on interview, records review, and observation, the licensee failed to give R1 a 30 day eviction notice due to change in condition, for which a reassessment was not completed or issued. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
11/04/2022
Section Cited
CCR
87705(k)(5)
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87705 Care of Persons with Dementia
(k)...Initial and continuing requirements must be met for the licensee to utilize... perimeter fence gates:(5)Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision.
This requirement was not met as evidenced by:
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All staff who provide direct care and supervision to residents will complete in-service training regarding Care of Persons with Dementia. A copy of the training material and the sign-in sheet will be provided to LPA via email by the POC due date.
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Based on interviews, records review, and observation, the licensee failed to supervise R1 outside of the facility due R1's desire to leave the facility on several occasions, following redirection. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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
10/17/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221017082225

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: 149DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Keren Mecham- AdminstratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report incident to CCL and Resident's Family.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with administrator Karen Meacham and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and conducted a tour of the physical plant with the administrator. LPA Maldonado also requested a copy of the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, Incident Reports for July-October 2022, and a copy of the eviction notice if available. Interviews were conducted with Staff# 1-7 (S1-S7).



(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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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-20221017082225
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: 10/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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Regarding allegation: Facility failed to report incident to CCL and Resident's Family.
It was alleged that R1, a memory care resident, had a series of incidents where R1 tried to leave the facility unassisted. Due to an increase of incidents, most of them being successful, the resident was sent to the hospital for a psych evaluation to determine if the resident needed a higher level of care. The facility has a secured memory care unit that is under surveillance and staffed with caregivers to oversee the residents. It is not a locked perimeter. During interviews conducted with S1-S7, (4) of (7) staff stated that the incident was reported to Community Care Licensing (CCL) and to R1's responsible party. Per the incident reports received and reviewed, facility staff did notify CCL and R1's responsible party. During a telephone interview conducted with R1's responsible party prior to the visit to the facility, R1's responsible party stated they were notified of previous incidents, but was not notified of R1 being transferred to a hospital for a psych evaluation until days after the incident occurred; However, they were still notified.

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 Administrator Karen Meacham 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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5