191500609-6-22-2023-28-AS-TVAO-CUDTUJ-20230804150224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:42:16 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
06/20/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230620141444

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: 148	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Priscilla Gaytan - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff denied resident a snack in between meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Priscilla Gaytan Administrator and explained the reason of the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster, copy of menu for the last month, and conducted interviews with residents #1-10 (R1-R10), staff #1-7(S1-S7).

The investigation revealed the following: Regarding allegation: Staff denied resident a snack in between meals. It is alleged a resident requested two slices of bread and staff ensure that resident did not receive the bread. Interviews with residents revealed 9 out 10 residents interview stated facility provides snacks and are available throughout the day. One (1) resident stated facility denied resident bread to make own sandwich.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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-20230620141444

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: 06/22/2023

NARRATIVE

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Interviews with staff reveal 4 out of 7 staff stated residents are redirected to the available snacks when they request something other than what is available or offered to prepare a sandwich for them. 2 out of 7 staff stated whenever a resident request for something they provide it to them. LPA observed a table in the dining room set up with water, crackers, and fruit. Menu reviewed does not list snacks provided. However, based on interviews snacks provided meet the snack guidelines and are available throughout the day for residents. Administrator will work with the residents' preferences based on residents' needs.

Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Priscilla Gaytan Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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