191500609-3-24-2023-28-AS-RORN-CRXVLP-20230518163215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 03/24/2023
Date Signed: 03/24/2023 02:16:47 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
03/22/2023 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230322101651

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: 147	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Priscilla Gaytan (Administrator), Karen Meacham (Administrator)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff hit resident.
Staff are not providing adequate food service to resident.
Staff did not ensure resident was served food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Priscilla Gaytan (Administrator), Karen Meacham (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, Interviewed Staff #1 to #3 in the library, toured the kitchen with Staff #1 and reviewed video footage in the Administrator's office.

In regards to the allegation: Staff hit resident. Complaint alleged that Staff hit Resident in the dining area at approximately 3:15 pm on 03/20/23. Based on interviews with Resident (R#1) and Staff, R#1 stole cookies from the kitchen. LPA reviewed video footage of the incident and observed that Staff reach towards R#1 in an attempt to receive the stolen cookies from R#1 but without success and did not observed Staff hitting R#1. Staff denied hitting R#1. Continue to LIC9099C.....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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-20230322101651

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: 03/24/2023

NARRATIVE

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In regards to the allegation: Staff are not providing adequate food service to resident. It was alleged that R#1 asked kitchen Staff for a sandwich on 3/20/23 but kitchen Staff did not provide it for R#1. LPA verified via video footage that R#1 entered the kitchen area at 5:28 pm and was provided a sandwich at 5:31 pm. Interview with Staff indicate a sandwich was provided to R#1.

In regards to the allegation: Staff did not ensure resident was served food. It was alleged that Staff did not served R#1 breakfast or lunch on 03/20/23. LPA review video footage and observed that on 03/20/23 at 8:04 am, Staff delivered breakfast to R#1's bedroom. Video footage also revealed that R#1 entered the dining area at 8:12 am and threw a tray of breakfast on the dining area floor further revealing R#1 had position of breakfast. At 11:32 am, video footage revealed that lunch was also deliver to R#1's bedroom. Interview with Staff indicate breakfast and lunch was delivered to R#1's bedroom on 03/20/23.

Based on LPA's interviews and observations, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Priscilla Gaytan and Karen Meacham and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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