191500609-4-7-2021-28-AS-MVAO-C2ARBC-20210421125231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 04/07/2021
Date Signed: 04/07/2021 12:00:23 PM

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
03/23/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210323114252

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 161	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Fern Key, administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.
Resident's bed is in disrepair.
Resident is not receiving proper nutrition at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Fern Key, administrator. The initial complaint visit was conducted on 3/24/21.

The investigation consisted of the following: During the initial visit administrator and Resident #1 (R1) were interviewed and a virtual tour of R1's room was conducted. LPA obtained copies of R1's file including but not limited to physician's report, wound care assessment, home health information, and food menu. During the subsequent complaint visit, interview was conducted with Staff #1 (S1) who is a Licensed Vocational Nurse (LVN) and R1's home health nurse.

Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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-20210323114252

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: 04/07/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Resident sustained multiple pressure injuries while in care. Facility staff interviewed indicated they are only aware of 1 stage II wound on R1's buttock. Facility staff indicated home health has been treating the wound and has been improving. Facility staff also indicated they have been following the care plan provided by the home health agency. A home health document dated 3/11/21 indicates a wound specialist evaluated the wound and it was diagnosed as a stage II wound on the right buttock. R1's home health nurse was interviewed. The nurse confirmed R1 only has 1 stage II wound on the right buttock. The nurse indicated he/she visits 3 times a week to treat the wound and has no concerns about R1's level of care at the facility. R1 was interviewed and he/she indicated they are comfortable at the facility. The care plan was reviewed and appears to be acceptable for the level of care R1 needs. Title 22 Regulations allows facilities to retain residents with stage I and stage II wounds as long as a detailed care plan is created by a medical professional and is followed by the facility. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Resident's bed is in disrepair. A virtual tour of R1's room was conducted. Facility staff assisted with adjusting the hospital bed higher and lower. The bed was working properly. Facility staff deny the bed was ever broken. Home health nurse also indicated the bed was never in disrepair. R1 indicated his/her bed has been working fine and was never broken. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Resident is not receiving proper nutrition at the facility. Facility staff interviewed deny the allegation. Home health nurse indicated R1's appetite has improved recently and R1 is eating more. Home health nurse indicated there hasn't been any drastic changes in R1's weight and has no concerns over R1's nutrition. R1 was interviewed and he/she indicated they like the food and has had no issues with eating the facility food.

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 allegations are unsubstantiated.

A telephonic exit interview was conducted with Fern Key, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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